PLEASE MAIL YOUR COMPLETED FORM TO:
Qualstar Credit Union PO Box 96730 Bellevue, WA 98009
E L I G I B I L I T Y / M E M B E R I N F O R M AT I O N
EMPLOYER (List Company Name / Store # / Facility)
THIS S PACE O R C R E D I T U Please complete the Fhighlighted N I O N U Sand LY: areas E O N return to any Qualstar branch. ACCOUNT #
YOUR Eligibility IS THROUGH (Check one only):
COMMUNITY (Community You Live or Work In) _________________________________________________
_____________________________________________
FAMILY MEMBERSHIP (List Family Member's Name and Social Security #):
YOUR LAST NAME FIRST
Name_________________________________________________________
MIDDLE JOINT ACCOUNT OWNER LAST NAME
SSN ____________________________________________________________
MIDDLE
(With Right of Sur vivorship)* FIRST
STREET ADDRESS
STREET ADDRESS
CITY
STATE
ZIP
CITY
STATE
ZIP
HOME PHONE
WORK PHONE
HOME PHONE
WORK PHONE
SOCIAL SECURITY NUMBER
DATE OF BIRTH
MOTHER’S MAIDEN NAME
SOCIAL SECURITY NUMBER
DATE OF BIRTH
MOTHER’S MAIDEN NAME
DRIVER’S LICENSE/STATE ID/PASSPORT #
ISSUE DATE
EXP. DATE
DRIVER’S LICENSE/STATE ID/PASSPORT #
ISSUE DATE
EXP. DATE
* Joint Account Owners will ha ve an interest in all ser
vices provided under this account.
ACCOUNT S AND SERVICES REQUES TED
SAVINGS (Limit of [3] withdrawals per month to avoid transaction fee*) STAR, 24-HOUR TELEPHONE TELLER FREE INTERNET HOME BANKING WITH BI LL PAYE R CHECK CARD SIMPLY CHECKING (Unlimited transactions - no monthly service fees! See check order section below) PREMIER CHECKING (Unlimited transactions - no monthly service fees! See check order section below) MONEY MARKET ACCOUNT (See check order section below) HOLIDAY CLUB YOUTH ACCOUNT (StarSavers 0-12 years; MyCa$h 13-17 years) SHARE CERTIFICATES IRA
LOA N S R E Q U E S T E D
I WOULD LIKE TO APPLY FOR A LOAN. * Please select the type of loan(s) you are interested in: AUTO VISA CLASSIC VISA GOLD MOTORCYCLE BOAT / RV EQUITY MORTGAGE OTHER
By checking the above box and signing below you are authorizing Qualstar Credit Union to obtain your credit report. You will be contacted regarding your request.
*All loans are based on approved credit. Restrictions may apply.
*See Rate & Schedule for more information on rates, terms and applicable fees.
C H E C K O R D E R I N F O R M AT I O N
You have the option of ordering checks* on checking and money market accounts. Please fill out the information below to receive basic Qualstar checks. Your account will be charged for your check order. Please contact Qualstar for current check prices. Check Starting # ______________________________________________
Please print my checks with the following information: NAME PHONE # JOINT NAME ADDRESS DRIVER’S LICENSE # OTHER ____________________________________________________________
*Credit approval required for check writing and ATM deposit services.
D I R E C T D E P O S I T / PAY R O L L D E D U C T I O N R E Q U E S T
Direct Deposit/Payroll Deduction is the most convenient way to have your funds deposited to your Qualstar Account. If your employer offers this service and you would like to have all or part of your paycheck deposited directly to Qualstar, please fill out the information below.
q YES! I would like to sign up for Direct Deposit/Payroll Deduction.
Employer Name: ________________________________________________________
We will mail you a letter with instructions on how to set up Direct Deposit to Qualstar. The instruction letter you receive is based on your employer, so please be sure to provide the name of your employer above.
A U T H O R I Z AT I O N
By signing below I/We agree to the terms and conditions of the Membership and Account Agreement, Truth-in-Savings Rate and Fee Schedule, 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 Agreement and Disclosure applicable to the accounts and services requested herein. If an ATM card or EFT service is requested and provided, I/we agree to the terms of and acknowledge receipt of the Electronic Funds Transfer Agreement. I/We authorize Qualstar to check my/our credit, verify employment history, obtain a credit report and to answer questions about its credit experience with me/us. The above information is true and complete to the best of my/our knowledge. I/We understand that it may be a federal crime punishable by fine or imprisonment, or both, to knowingly make any false statements concerning any of the above facts as applicable under the provisions of the United States Criminal Code. q I am subject to backup withholding. q I am not a United States citizen or resident (complete W-8). q I am Exempt.
X ____________________________________________________________________________ X ____________________________________________________________________________
SIGNATURE OF MEMBER DATE SIGNATURE OF JOINT OWNER DATE