Home > Connect With Us > Join Connected CU > Membership Application 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: 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 2045 Social Security Number: Citizenship Status: Select... U.S. Citizen Permanent Resident Non-Permanent Resident 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 No The Taxpayer Identification Number given is correct (A Social Security Number is an example of a TIN) Yes No 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 No I am exempt from Foreign Account Tax Compliance Act (FATCA) reporting Yes No 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: Select... AK AL AR AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY ZIP: Housing/Residence Type: Select... Live with Parents Military Housing Own/Buying Rent Room/Board Other Monthly Housing Expense: Years and Months at Address: Previous Address: Previous Address 2: City: State: Select... AK AL AR AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY ZIP: Housing/Residence Type: Select... Live with Parents Military Housing Own/Buying Rent Room/Board Other Years and Months at Address: Employment Status: Select... Full-time Part-time Temporary Unemployed Your Work Title: Name of Employer: Years and Months on Job: Gross Annual Salary: Preferred Contact Number: Extension: Email Address: Preferred Contact Method: Select... Day Phone Email Evening Phone Mobile Phone 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: Select... Driver's License Military State ID Matricula Consular Passport Credencial Para Votar ID Number: ID State: Select... AK AL AR AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY ID Country: ID Issue Date: ID Issue Date: Month Month... January February March April May June July August September October November December / ID Issue Date: 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 / ID Issue Date: 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 2045 ID Expiration Date: ID Expiration Date: Month Month... January February March April May June July August September October November December / ID Expiration Date: 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 / ID Expiration Date: 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 2045 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: Date: Month Month... January February March April May June July August September October November December / Date: 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: 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 2045 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.
