PLEASE MAIL YOUR COMPLETED FORM TO:
Qualstar Credit Union
THIS S PACE O R C R E D I T U
areas E O N return to any
Please complete the Fhighlighted N I O N U Sand LY:
PO Box 96730 Qualstar branch.
ACCOUNT #
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 YOUR Eligibility IS THROUGH (Check one only):
EMPLOYER (List Company Name / Store # / Facility) _____________________________________________ COMMUNITY (Community You Live or Work In) _________________________________________________
FAMILY MEMBERSHIP (List Family Member's Name and Social Security #): Name_________________________________________________________ ____________________________________________________________
SSN
JOINT ACCOUNT OWNER (With Right of Sur vivorship)*
YOUR LAST NAME FIRST MIDDLE LAST NAME FIRST MIDDLE
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 LOA N S R E Q U E S T E D
SAVINGS (Limit of [3] withdrawals per month to avoid transaction fee*) I WOULD LIKE TO APPLY FOR A LOAN. *
STAR, 24-HOUR TELEPHONE TELLER Please select the type of loan(s) you are interested in:
FREE INTERNET HOME BANKING WITH BI LL PAYE R AUTO BOAT / RV
CHECK CARD VISA CLASSIC EQUITY
SIMPLY CHECKING (Unlimited transactions - no monthly service fees! See check order section below) VISA GOLD MORTGAGE
PREMIER CHECKING (Unlimited transactions - no monthly service fees! See check order section below) MOTORCYCLE OTHER
MONEY MARKET ACCOUNT (See check order section below)
By checking the above box and signing below you are authorizing Qualstar Credit
HOLIDAY CLUB
Union to obtain your credit report. You will be contacted regarding your request.
YOUTH ACCOUNT (StarSavers 0-12 years; MyCa$h 13-17 years)
SHARE CERTIFICATES *All loans are based on approved credit. Restrictions may apply.
IRA
*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 print my checks with the following information:
Please fill out the information below to receive basic Qualstar checks. Your NAME PHONE # JOINT NAME
account will be charged for your check order. Please contact Qualstar for current ADDRESS DRIVER’S LICENSE #
check prices. OTHER ____________________________________________________________
*Credit approval required for check writing and ATM deposit services.
Check Starting # ______________________________________________
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