Account Type

All of the terms, conditions, form of account ownership, account selection and other information indicated on this card apply to all of the accounts listed below unless the credit union is notified in writing of a change.
	Suffix*		Suffix*
Share/Savings Share Draft/Checking Share Certificate		Money Market Living Trust Other
*The account number for each of the accounts listed above consists of the suffix added to the end of the Member Number listed below. If this card applies to more than one account of the same type, more than one suffix will be listed for that account type.

Member Application and Ownership Information

		Member No.:
Member/Owner:
Street:		SSN/TIN:
City/State/Zip:		Driver’s Lic. No.:
Home Phone:	Listed Unlisted	Date of Birth:
Work Phone:		Password:
E-Mail:		Employment:
Eligibility for Membership:

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) 1 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 U.S. person (including a U.S. resident alien). Certification Instructions. Cross out item 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 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 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 provisions of this document other than the certifications required to avoid backup withholding.

X __________________________ ___________
Applicant Signature Date

X ___________________________ __________
Co-Applicant Signature Date

X __________________________ ___________
Applicant Signature Date

X ___________________________ __________
Co-Applicant Signature Date

Account Services

Payroll Deduction/Direct Deposit	ATM Card
Audio Response	Debit Card
PC Access/Internet Banking	Overdraft Protection (Indicate transfer priority below)
Other:

Account Ownership

Designate the ownership of the accounts and responsibility for the services requested.

Individual Joint Account with Survivorship Joint Account without Survivorship

Joint Owner

Name:		SSN/TIN:
Street:		Driver’s Lic. No:
City/State/Zip:		Date of Birth:
Home Phone:	Listed Unlisted	Password:
Work Phone:		E-Mail:

Joint Owner

Name:		SSN/TIN:
Street:		Driver’s Lic. No:
City/State/Zip:		Date of Birth:
Home Phone:	Listed Unlisted	Password:
Work Phone:		E-Mail:

Account Designations

Payable on Death (POD)/Trust Account All accounts Designate specific account(s)

Beneficiary/ POD Payee:		Beneficiary/ POD Payee:
Street:		Street:
City/State/Zip:		City/State/Zip:

Agency
All Accounts
Designate specific account(s)

Name of Agent:

Signature: ___________________________________________

UTTMA/UGMA (as custodian for _________________________________________________ (minor) under the Uniform Transfers/Gifts to Minors Act) Minor’s TIN/SSN:
Other See Account Authorization Card

For Credit Union Use Only

See Account Change Card See Insurance Beneficiary Card Date of Membership: Open/App'd by: Member Verification:
Credit Report	Check Verify	PIN Request
Access Card	Audio Response	PC Access/Internet Banking