* Indicates Required
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. All accounts require a share/savings account with a minimum $25.00 membership balance.
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.
Under penalties of perjury, I certify that:
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. Complete a W-8 BEN if you are not a U.S. person. If a W-8 BEN is completed, your signature does not serve to certify this section.
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.