Membership Application Savings Only

Member Application and Ownership Information

(*) indicates a required field

Disclosures*

Yes, I've read and agree to the following:

You must agree to the disclosures to proceed!

After you submit your application, we’ll automatically email you our disclosure PDFs for your records.

Your application will be reviewed within 24 business hours. Once approved, you’ll receive a secure email to electronically sign your membership card, upload required identification, and fund your initial deposit of $10 ($5 non-refundable membership fee and $5 savings deposit).

Accepted identification includes a state-issued driver’s license or ID, or a U.S. passport. If the address on your ID does not match your application, additional proof of address (such as a utility bill or bank/credit card statement) will be required. Proof of eligibility is also required.

Please contact us if you have any questions!

First Name*

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Middle Name

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Last Name*

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Street (cannot be a P.O. Box)*

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City*

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State*

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Zip Code*

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Is your mailing address different than above?

Check here if your mailing address is different than above

You must agree to the disclosures to proceed!

Mailing Address*

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City*

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State*

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Zip Code*

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Primary Phone Number*

Please enter your primary phone number

Secondary Phone Number

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E-Mail Address*

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Social Security Number/TIN*

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ID Type*

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State Issued ID Number*

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State of Issue*

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Expiration Date*

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Passport Number*

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Expiration Date*

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Birthdate (MM/DD/YYYY)*

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Mother's Maiden Name*

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Membership Eligibility*

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Elegibility Information*

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Account Ownership

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

Account Ownership*

Individual

Joint

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Joint Owner Information

First Name*

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Middle Name

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Last Name*

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Is you address same as primary applicant?

Check here if you address is the same as Primary Applicant

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Physical Address*

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City*

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State*

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Zip/Postal Code*

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is your mailing address different than above?

Check here if your mailing address is different than above

You must agree to the disclosures to proceed!

Mailing Address*

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City*

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State*

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Zip/Postal Code*

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Primary Phone Number*

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Secondary Phone Number

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Social Security Number*

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ID Type*

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State Issued ID Number*

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State of Issue*

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Expiration Date*

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Passport Number*

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Expiration Date*

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Birthdate (MM/DD/YYYY)*

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Mother's Maiden Name*

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E-Mail Address*

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Would you like to add another Joint Owner?

Yes

No

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First Name*

Invalid Input

Middle Name

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Last Name*

Invalid Input

Is you address same as primary applicant?

Check here if you address is the same as Primary Applicant

Invalid Input

Physical Address*

Invalid Input

City*

Invalid Input

State*

Invalid Input

Zip/Postal Code*

Invalid Input

is your mailing address different than above?

Check here if your mailing address is different than above

You must agree to the disclosures to proceed!

Mailing Address*

Invalid Input

City*

Invalid Input

State*

Invalid Input

Zip/Postal Code*

Invalid Input

Primary Phone Number*

Invalid Input

Secondary Phone Number

Invalid Input

Social Security Number*

Invalid Input

ID Type*

Invalid Input

State Issued ID Number*

Invalid Input

State of Issue*

Invalid Input

Expiration Date*

Invalid Input

Passport Number*

Invalid Input

Expiration Date*

Invalid Input

Birthdate (MM/DD/YYYY)*

Invalid Input

Mother's Maiden Name*

Invalid Input

E-Mail Address*

Invalid Input

Account Designations

Payable-On-Death Account Beneficiary Designation

Upon the death of the last surviving owner, the funds in Your Account shall become the property of the beneficiary(ies) listed below who are alive at that time. You may change the beneficiary(ies) identified below only with the written consent of all owners to the Account.

Please note: If you elect multiple beneficiaries and you do not allocate percentages to each beneficiary, the funds will be split equally among the surviving beneficiaries.

Number of beneficiaries*

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Full Name, First Beneficiary/POD Payee *

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Address*

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City*

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State*

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Zip/Postal Code*

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Social Security Number*

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Birthdate (MM/DD/YYYY)*

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Percentage

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Full Name, Second Beneficiary/POD Payee *

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Address*

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City*

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State*

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Zip/Postal Code*

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Social Security Number*

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Birthdate (MM/DD/YYYY)*

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Percentage

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Please note the percentages allocated to your beneficiaries must equal 100 percent in order to submit your application.

Account Type

All of the terms, conditions, form of account ownership, account selection and other information indicated on this form apply to all of the accounts listed unless the Credit Union is notified in writing of a change.

Account Type(s)*

Share/Savings (Required for Membership) - $10 ($5 Min. Deposit and $5 Membership Fee)

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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 form applies to more than one account of the same type, more than one suffix will be listed for that account type.

Account Services

Check All That Apply*

Audio Response

Online Banking

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Are you interested in receiving information about Payroll Deduction/Direct Deposit on your new accounts?*

Yes

No

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Taxpayer Identification Number Certification and Backup Withholding Information

Have been notified by the IRS that you are currently subject to backup withholding because you failed to report all interest and dividends on your tax return?

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Are you a U.S. Citizen or other U.S. Person (including U.S. Resident Alien)

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You have answered that you are NOT a US citizen. Please provide a completed IRS W-8 BEN Form.

Check the following

(1) The number shown on this form is my correct taxpayer information number (or I am waiting for a number to be issued), and

(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, and

(3) I am a U.S. citizen or other U.S. person (including U.S. resident alien)

(4) The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

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We will be unable to open an Account for You without a taxpayer identification number.

Exempt payee code (if any)

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Exemption from FATCA reporting code (if any)

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Authorization*

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.

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Member Application and Ownership Information

Account Ownership

Joint Owner Information

Account Designations

Payable-On-Death Account Beneficiary Designation

Account Type

Account Services

Taxpayer Identification Number Certification and Backup Withholding Information

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