Membership Application

Thank you for applying for membership with our Credit Union. This process will take about 5 to 10 minutes to complete.

As a part of opening your account, we require that you create a savings account that has a minimum opening balance. This account makes you a part owner of the Credit Union!

To get started, we'd like to find out about what we can do to help serve your financial needs!

* Will this be an individual or a joint account?

Individual Account

Joint Account

* Account Types:

Primary Savings

Please select additional desired products from the list below:

Checking

Money Market

Secondary Savings

Certificate of Deposit

Please select the services you would be interested in below:

Order Checks

Debit Card

Online Banking

Overdraft Protection

Mother's Maiden Name:

Important Information About Procedures for Opening a New Account: To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

What this means for you: When you open 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.

First Name:

Middle Name:

Last Name:

Date of Birth:

/ /

Social Security Number:

Citizenship Status:

Complete the following if you are a U.S. Citizen or a U.S. Resident Alien. Do not complete if you are a Non-Resident Alien (we will request a W-8BEN).

* I am a U.S. person (including a U.S. resident alien)

Yes

The Taxpayer Identification Number given is correct (A Social Security Number is an example of a TIN)

Yes

I have not been notified by the IRS that I underreported or failed to report interest or, if so, that the IRS has notified me that I am no longer subject to backup withholding

Yes

I am exempt from Foreign Account Tax Compliance Act (FATCA) reporting

Yes

Complete the information below to provide us with your current address. If residing at your Current Address less than 2 years, use the Previous Address sections to provide any additional address history.

Address:

Address 2:

City:

State:

ZIP:

Housing/Residence Type:

Monthly Housing Expense:

Years and Months at Address:

Previous Address:

Previous Address 2:

City:

State:

ZIP:

Housing/Residence Type:

Years and Months at Address:

Employment Status:

Your Work Title:

Name of Employer:

Years and Months on Job:

Gross Annual Salary:

Preferred Contact Number:

Extension:

Email Address:

Preferred Contact Method:

By providing your number and email address, you authorize us and our service providers to contact you regarding your application(s), including by autodialed calls, text messages, and emails. You certify the information is correct and you agree to receive email confirmation of your requests.

Provide your identification information below. You can upload your picture ID below. Please note these documents are required in order to process your application.

Identification Type:

ID Number:

ID State:

ID Country:

ID Issue Date:

/ /

ID Expiration Date:

/ /

TERMS AND CONDITIONS

Read the important information below before submitting your request. Depending on the nature of this request, these disclosures may contain important information regarding applicable rates, fees and other costs.

Important Disclosures

By submitting this request, you authorize the Credit Union to obtain a ChexSystems report in connection with this request. You understand that the Credit Union will rely on information in this request and the ChexSystems report to make its decision.

Note: A confirmation email will be sent to the email address provided confirming we received your membership application.

Membership request is subject to review and approval and an account with a minimum deposit needs to be opened. Individuals are required to become a member before being eligible to receive a loan or other Credit Union products and services.

By signing the box(es) below and submitting this request, all parties named below are agreeing to the terms, conditions and disclosures associated with this request. It is a crime to willfully and deliberately provide incomplete or incorrect information in this request.

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

In order to help expedite the processing of your membership application, you have the option to upload a photo of your identification document. Note: Federal law (18 U.S.C. 701) prohibits copying, scanning, and uploading military badges or military ID cards.:

Type Your Name to Provide Your Signature:

Date:

/ /

By clicking "Submit", all parties agree the typing of their name constitutes an electronic signature which is the legal equivalent of a written signature and is a binding and enforceable signature.

Join Connected Credit Union