MCT FCU

Membership Application

March 1, 2007, 6:13 AM EST

Account Types

Draft:

___ yes ___ no

Savings:

___ yes ___ no

Account ID: ____________________

Social Security Number: _____-_____-________

First Name: ____________________

Middle Name: ____________________

Last Name: ____________________

Email Address: ____________________

Home Phone: _____-_____-________

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:

________________________________