A A A * Required Fields On October 26, 2001, President Bush signed into law the USA Patriot Act. The purpose of this law is to help protect you, your family and our country from terrorism by preventing terrorist financing. We want you to know that section 326 of this Act requires our credit union to verify the identity of all new credit union members. We must also verify the identity of members and nonmembers added as signatories to and have access to new or existing deposit accounts and loans. We must retain copies of documents used to verify your identity. If you are an existing member who joined the credit union before the USA Patriot Act rules became effective we may also need to verify and retain copies of any documents used to verify your identity when you request a new deposit account, apply for a loan or are added as a signatory to a new or existing deposit or loan account. We are asking for your understanding as we work to support these efforts to maintain the security of your funds and our country. Please speak to a credit union staff member if you have any questions or concerns about identification policies. Will there be a co-applicant on this application? Yes No I am interested in: Checking Account Type of Checking Account: Initial Deposit Amount $: Source of Deposit: Transfer from a current account I will transfer funds from another financial institution I will mail a check/money order Other (please describe) If Transfer, please enter Account Number: If Other, please describe: I am interested in: Savings Account Type of Savings Account: Source of Deposit: Transfer from a current account I will transfer funds from another financial institution I will mail a check/money order Other (please describe) If Transfer, please enter Account Number: If Other, please describe: I am interested in: Other Account Description: Initial Deposit Amount $: Source of Deposit: Transfer from a current account I will transfer funds from another financial institution I will mail a check/money order Other (please describe) If Transfer, please enter Account Number: If Other, please describe: I am also interested in: ATM Card ATM and Check/Debit Card Credit Card Direct Deposit Other (please describe) If Other, please describe: Primary Applicant Member Number: Last Name: First Name: Middle Name: Social Security Number (TIN): Social Security Number (TIN): Social Security Numer Field 1 - Social Security Number (TIN): Social Security Numer Field 2 - Social Security Number (TIN): Social Security Numer Field 3 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 Home Phone Number: Work Phone Number: Cell or Other Phone: Email Address: Driver's License #: Driver's License State: 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 Drivers License Expiration Date: Mother's Maiden Name: Present Employer Name: Home Address Address 1: Address 1 2: City: State: 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 ZIP: Co-Applicant Member Number: Last Name: First Name: Middle Name: Social Security Number (TIN): Social Security Number (TIN): Social Security Numer Field 1 - Social Security Number (TIN): Social Security Numer Field 2 - Social Security Number (TIN): Social Security Numer Field 3 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 Home Phone Number: Work Phone Number: Email Address: Cell or Other Phone: Driver's License #: Driver's License State: 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 Drivers License Expiration Date: Mother's Maiden Name: Present Employer Name: Home Address Address: Address 2: City: State: 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 ZIP: Additional Information How would you like to be contacted? Home Phone Work Phone Cell or Other Phone Email Other If Other, please describe: Special Instructions / Comments: Security Code: Security Code
