Membership Application

MEMBERSHIP ELIGIBILITY

Work (name of employer)
Family/Relative of someone eligible for membership: (Relative's Name )

MEMBER INFORMATION

Member Name:
Member No.
Address:
Email:
City/State/Zip:
SSN:
Home Phone:

Cell Phone: 

Birth Date:
Employer:
Drivers License No.:
Work Phone:
Exp. Date:

State:

ACCOUNT OWNERSHIP

Joint Account with Right of Survivorship

Joint Owner #1

Member Name:
Address:
Email:
City/State/Zip:
SSN:
Home Phone:

Cell Phone:

Birth Date:
Employer:
Drivers License No.:
Work Phone:
Exp. Date:

State:

Joint Owner #2

Member Name:
 
Address:
Email:
City/State/Zip:
SSN:
Home Phone:

Cell Phone:

Birth Date:
Employer:
Drivers License No.:
Work Phone:
Exp. Date:

State:

Payable on Death (POD) Account

All Accounts   
Beneficiary:   Beneficiary:
UTMA Account (list minor's name and TIN here):

TIN AND BACKUP WITHOULDING CERTIFICATION

By signing below, I certify under penalties of perjury that: (i) I am a US citizen or other US person, (ii) the Social Security Number (SSN)/Taxpayer Identification Number (TIN) shown is my correct identification number, and (iii) I am NOT, unless designated below, subject to backup withholding because I am exempt or I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all dividends or interest, or because the IRS has notified me that I am no longer subject to backup withholding.
I am subject to backup withholding
I am not a United State citizen or resident alien (complete W-8 BEN)
I am exempt from withholding

AUTHORIZATION

By signing below, I/we agree to the terms and conditions of the Membership and Account Agreement, Truth-in-Savings Disclosures & Rate and Fee Schedule, Funds Availability Policy Privacy Policy and Electronic Funds Transfer Agreement and to any amendment you make from time to time which are incorporated herein. I/We acknowledge receipt of a copy of the Agreements and Disclosures applicable to the accounts and services requested above. The Internal Revenue Service does not require your consent to any provision of this Account Card other than the certifications required to avoid backup withholding.