To simplify the process of registering for an account, we offer this web based form that you can fill out now and print. If you would prefer to download the form as a Word document, you may do so by clicking here.
 


ACCOUNT CARD
 

ACCOUNT TYPE
Share / Savings
Share Certificate / Certificate

Money Market
Other:
Other:

 
TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION
By signing below, I certify, in accordance with the IRS W-9 instructions by the Credit Union and under penalties of perjury, that the Social Security number (SSN) / Taxpayer identification number (TIN) shown is my / the correct identification number and that I am NOT, unless designated below, subject to backup withholding because I have not been notified 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
Exempt

I am not a United States citizen or resident
       (complete W-8 form)

 
MEMBER APPLICATION AND OWNERSHIP INFORMATION
Member
Street
City / State / Zip
Phone Home
Phone Work
Account No.
SSN / TIN
Driver's Lic No.
Date of Birth
Mother's Maiden Name
 
Employment
Eligibility for Membership

 
AUTHORIZATION

By signing below, I / we agree to the terms and conditions of the Membership and Account Agreement, Truth-in-Savings Rate and Fee Schedule, 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 Disclosure applicable to the accounts and services requested herein. If an access card or EFT service is requests and provided, I / we agree to the terms of and acknowledge receipt of the Electronic 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.

 
X_____________________________________
       Signature                                                   Date

X_____________________________________
       Signature                                                   Date
 X_____________________________________
       Signature                                                   Date

X_____________________________________
       Signature                                                   Date
©CUNA Service Group, Inc., 1996, 1993
     Printed in USA
® By Union Labor
Reorder from your League or
CUNA Customer Service 1-800-356-8010		 D1100-FK1 Rev. 6/97

 

ACCOUNT SERVICES

Payroll Deduction / Direct Deposit
Other

Other EFT Service:
Other:

 
ACCOUNT OWNERSHIP
Designate the ownsership of the accounts for the services requested
 
Single Party           Multiple Party with Survivorship             Multiple Party without Survivorship

 
MEMBER APPLICATION AND OWNERSHIP INFORMATION
Joint Owner   SSN / TIN
Street   Driver's Lic. No.
City / State / Zip   Date of Birth
Phone Home Work Mother's Maiden Name
Joint Owner   SSN / TIN
Street   Driver's Lic. No.
City / State / Zip   Date of Birth
Phone Home Work Mother's Maiden Name
Other See Account Authorization Card
 
ACCOUNT DESIGNATIONS

Payable on Death (POD) / Trust Account

Beneficiary
Street
City / State / Zip

All accounts        Designate specific account(s)

Beneficiary
Street
City / State / Zip
   
UTTMA / UGMA (as custodian for (minor) under the Uniform Transfers / Gifts to Minor's Act)
Minor's TIN / SSN
Agency           Name of Agent
      All Accounts           Designate specific account(s)
FOR CREDIT UNION USE
See Account Charge Card
Date of Membership______________ Opened / App'd by _____________ Member Verification___________
PIN Request___________ Credit Report___________ Check Verify __________ Access Card____________