Membership Application Member Application and Ownership InformationMember/Owner* First Last Member No:*Designate the ownership of the accounts and responsibility for the services requested.* Individual Joint Account with Survivorship Joint Account without Survivorship Address* Street Address City State / Province / Region ZIP / Postal Code Driver's Lic. NO.*Date of Birth* Password*Membership Eligibility*Home Phone*Work PhoneEmail* Employer*Account OwnershipJoint Owner First Last Address Street Address City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneSSN/TIN*Driver's Lic. NO.*Date of Birth* Password*Email* 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 bellow, 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 if 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. Signature*Date* Signature*Date* Signature*Date* Signature*Date*
