Applicant Information:

Name:*
 
E-mail address:*
Phone:*
Social Security #:*
Driver's License Number:
Birth Date:
Present Address
City
State
Zip
Current Employer:
Employer's Phone:
   

Under penalties of perjury, I certify that:

(1) The number shown on this form is my correct taxpayer identification 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 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. citizen or other U.S. person. For federal tax purposes, you are considered a U.S. person if you are: an individual who is a U.S. citizen or U.S. resident alien; a partnership, corporation, company, or association created or o rganized in the United States or under the laws of the United States; an estate (other than a foreign estate); or a domestic trust (as defined in Regulations Section 301.7701-7).

Certification Instructions. Check the box for item 2 above if you have been notified by the IRS that backup withholding applies. By checking this box, this serves to strike out the language related to underreporting. Complete a W-8 BEN if yo u are not a U.S. person.

 

Account Type







   

Account Ownership

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

Individual Joint Account with Rights of Survivorship Joint Account without Rights of Survivorship

Joint Owner 1:
Present Address
City
State
Zip
Social Security #:
Birth Date:
Current Employer:
Employer's Phone:
   
Joint Owner 2:
Present Address
City
State
Zip
Social Security #:
Birth Date:
Current Employer:
Employer's Phone:
   

Account Designations

  All Accounts Designate Specific Accounts:

   
Beneficiary/POD Payee 1:
Present Address
City
State
Zip
   
Beneficiary/POD Payee 2:
Present Address
City
State
Zip
Name of Agent:
  All Accounts Designate Specific Accounts:
   

*Required fields.

By submitting this form, you hereby grant permission to the Credit Union to gather any relevant data on you necessary to complete your membership application. This is the first step in the membership process; you may be required to fill out and sign additional paperwork in person.

 

cuopen24.com is provided by Advanced Management Information Systems in partnership with your credit union. All materials herein, except credit union logo(s) 2015 Advanced Management Information Systems. All rights reserved.