Membership Application

  • Member Application and Ownership Information

  • Date Format: MM slash DD slash YYYY
  • Account Ownership

  • Date Format: MM slash DD slash YYYY
  • TIN Certification and Backup withholding Information

  • Under penalties of perjury, I certify that:
    (1) The number shown on this form is my correct taxpayer identification number.
    (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the internal Revenue Service (IRS) that i am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
    (3) I am a US. person (including a U.S. resident alien).

    Certification Instruction. Cross out items 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. Cross out item 3 and complete a W-8 BEN if you are not a U.S. person.

  • Authorization

  • By signing below, I/We agree to the terms and conditions of the Membership and Account Agreement, Truth-in-Savings Disclosure, Funds Availability Policy Disclosure, if applicable, and to any amendment the Credit Union makes from time to time which are incorporated herein. I/We acknowledge receipt of a copy of the Agreement and disclosures applicable to the accounts and services requested herein. If an access card or EFT service is requested and provided, I/We agree to the terms of and acknowledge receipt of the Electronic Funds Transfer Agreement. The internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

  • Use this box to leave an e-signature so that we may begin the account opening process. In order to finish the process, we will need your actual signature on file.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
    Required if a Joint Owner is being added.