| Joint Membership Application |
| March 1, 2007, 6:27 AM EST |
| Account Types |
| Draft: | ___ yes ___ no |
| Savings: | ___ yes ___ no |
| Account ID: ____________________ |
| Primary Applicant |
| Social Security Number: _____-_____-________ | First Name: ____________________ |
| Middle Name: ____________________ | Last Name: ____________________ |
| Email Address: ____________________ | Home Phone: _____-_____-________ |
| Street Address: ____________________ | Street Address: ____________________ |
| City: ____________________ | State: ____________________ |
| Zip: ____________________ | Country: ____________________ |
| Date of Birth: _____/_____/________ | Drivers License: ____________________ |
| Employer: ____________________ | Work Phone: _____-_____-________ |
| Name of Supervisor: ____________________ |
| Secondary Applicant |
| Social Security Number: _____-_____-________ | First Name: ____________________ |
| Middle Name: ____________________ | Last Name: ____________________ |
| Email Address: ____________________ | Home Phone: _____-_____-________ |
| Street Address: ____________________ | Street Address: ____________________ |
| City: ____________________ | State: ____________________ |
| Zip: ____________________ | Country: ____________________ |
| Date of Birth: _____/_____/________ | Drivers License: ____________________ |
| Employer: ____________________ | Work Phone: _____-_____-________ |
| Name of Supervisor: ____________________ |
| Pay On Death: |
| Authorization Notice: By submitting this
application to the credit union, you certify that everything you have
stated in this application is correct to the best of your knowledge. You
understand that the credit union will rely on the representations you
make in this application when deciding whether to grant membership. You
agree to immediately notify us of changes to any of the information you
have provided in this application. You understand that it is a federal
crime to willfully and deliberately provide incomplete or incorrect
information on applications made to Credit Unions or State Chartered
Credit Unions insured by NCUA. IMPORTANT INFORMATION: PROCEDURES FOR OPENING A NEW ACCOUNT To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. |
| Authorized Signature: | ________________________________ | Date: | ________________________________ |
| Authorized Signature: | ________________________________ | Date: | ________________________________ |