Fellowship Credit Union Membership

Fellowship Credit Union Membership Application

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 unless the Credit Union is notified in writing of a change.

  Account Type





*The account number for each of the accounts listed consists of the suffix added to the end of the Member Number listed in the "MEMBER APPLICATION AND OWNERSHIP INFORMATION" section. 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/Owner:
  Street
  City/State/Zip
  Home Phone:() -
  Phone Number is:

  Work Phone() - ext
  Membership Eligibility
  SSN/TIN: - -
  Driver's Lic. No
  Date of Birth / / (mm/dd/yyyy)
  Password
  Employer
  E-mail

TIN Certification and Backup Withholding Information

  Under penalties of perjury, I certify that (please check all that apply):



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 4 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 agreements 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 Fund Transfers Agreement and Disclosure. 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 / / (mm/dd/yyyy)
  Signature
  Date / / (mm/dd/yyyy)
  Account Services






ACCOUNT OWNERSHIP

  Designate the ownership of the accounts and responsibiity for the services requested


  Joint Owner:
  Street:
  City/State/Zip:
  Home Phone:() -
  Phone Number is:

  Work Phone:() - ext
  SSN/TIN: - -
  Driver's Lic. No
  Date of Birth / / (mm/dd/yyyy)
  Password:
  E-mail:
  Joint Owner:
  Street:
  City/State/Zip:
  Home Phone:() -
  Phone Number is:

  Work Phone:() - ext
  SSN/TIN: - -
  Driver's Lic. No
  Date of Birth: / / (mm/dd/yyyy)
  Password:
  E-mail:

Account Designations

  Account Designation
  Beneficial/POD Payee:
  Street
  City/State/Zip
  Beneficial/POD Payee:
  Street
  City/State/Zip
  Account Designation
  Minor (under the Uniform Transfers/Gifts to Minors Act)
  Minor's SSN/TIN: - -
  Account Designation

  Printed Name of Agent:
  Date / / (mm/dd/yyyy)
  Signature
  Account Designation

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Effective October 1, 2003

In accordance with section 326 of the USA Patriot Act, Fellowship Credit Union is required by Federal law to obtain, verify, and record information that identifies each person who opens an account or is being added as a signatory to a new or existing account. In some cases, identification will be requested for those banking with us prior to the effective date of the customer identification requirements because original documentation was not obtained with the opening of the accounts.

What this means for you:

When you open an account or are going to be added as a signatory to 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.

Equal Housing Lender National Credit Union Administration This Credit Union is federally-insured by the National Credit Union Administration.
We do business in accordance with the Fair Housing Law and Equal Opportunity Credit Act.