Fellowship Credit Union Membership Application

* Required Fields

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:

Share/Savings:(SUFFIX)_

Share Draft/Checking:(SUFFIX)_

Share Certificate/Certificate(SUFFIX):_

Money Market:(SUFFIX)_

HSA:(SUFFIX)_

Other:(SUFFIX)_

*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:

Select... AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Home Phone::

Phone Number is::

Work Phone:

Membership Eligibility:

SSN/TIN::

Driver's Lic. No:

Date of Birth:

Date of Birth: Month Month... January February March April May June July August September October November December  /  Date of Birth: Day Day... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  /  Date of Birth: Year Year... 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045

Password:

Employer:

E-mail:

TIN Certification and Backup Withholding Information

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

The number shown on this form is my correct taxpayer identification number

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

The IRS has notified me that I am no longer subject to backup withholding

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 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:

Signature:

Date:

Account Services:

Payroll Deduction/Direct Deposit_

Overdraft Protection(indicate transfer priority):_

PC Access/Internet Banking_

ATM Card_

Debit Card_

Audio Response_

Other (please specify)_____

ACCOUNT OWNERSHIP

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

Individual

Joint Account with Rights of Survivorship

Joint Account without Rights of Survivorship

Joint Owner::

Street::

City/State/Zip::

Select... AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Home Phone::

Phone Number is::

Work Phone::

SSN/TIN::

Driver's Lic. No:

Date of Birth:

Date of Birth: Month Month... January February March April May June July August September October November December  /  Date of Birth: Day Day... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  /  Date of Birth: Year Year... 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045

Password::

E-mail::

Joint Owner::

Street::

City/State/Zip::

Select... AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Home Phone::

Phone Number is::

Work Phone::

SSN/TIN::

Driver's Lic. No:

Date of Birth::

Date of Birth:: Month Month... January February March April May June July August September October November December  /  Date of Birth:: Day Day... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  /  Date of Birth:: Year Year... 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045

Password::

E-mail::

Account Designations

Account Designation:

Payable on Death (POD)/Trust Account

Beneficial/POD Payee::

Street:

City/State/Zip:

Select... AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Beneficial/POD Payee::

Street:

City/State/Zip:

Select... AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Account Designation:

UTMA/UGMA (as custodian for

Minor (under the Uniform Transfers/Gifts to Minors Act):

Minor's SSN/TIN::

Account Designation:

Agency

Agent only for HSA

Printed Name of Agent::

Date:

Signature:

Account Designation:

Other_

See Account Authorization Card

Security Code:

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.