Account Application Orange County’s Credit Union
MEMBER INFORMATION
Credit Union Member Number (for update only) First Name Street Address Mailing Address (if different from above) Home Phone Length of Employment Work Phone Employer Address
o NEW
ID or Drivers License Number Middle Name City City Employer City State State Last Name State State
o UPDATE
Member E-mail Address Date of Birth ZIP ZIP Occupation Zip Length of Residence Rent or Mortgage $ o Rent o Own
o Other Gross Monthly Income
$
Mother’s Maiden Name If I am not currently a member, I hereby make application for membership in Orange County’s Credit union and agree to conform to its bylaws the terms and conditions of the Account Agreement and Truth in Saving Disclosures (which are herein incorporated by this reference as if se forth in full) and authorize the Credit Union to gather on a periodic basis whatever checking account, credit and employment information the Credit Union deems appropriate. This application supersedes all prior applications for this account. 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.
REQUEST FOR SOCIAL SECURITY NUMBER OR TAXPAYER IDENTIFICATION NUMBER
Under penalties of perjury, I certify that: Part 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and Part 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and Part 3. I am a U.S. citizen or other U.S. person (including a U. S. resident alien) Enter your Taxpayer Identification Number (TIN)
JOINT OWNER (S) INFORMATION (First Joint Owner)
First Name Street Address Work Phone Middle Name City ID or Drivers License Number Last Name State State ZIP Social Security Number Date of Birth Home Phone Mother’s Maiden Name
JOINT OWNER (S) INFORMATION (Second Joint Owner)
First Name Street Address Work Phone Middle Name City ID or Drivers License Number Last Name State State ZIP Social Security Number Date of Birth Home Phone Mother’s Maiden Name
Pay-on Death Provision / Beneficiary
Name of Payee / Beneficiary Address of Payee / Beneficiary Middle Name City Last Name State ZIP Date of Birth (optional) Social Security Number (optional)
ELIGIBILITY
How Eligible for Membership Name of Employer Family Member Name Member Number SEG Code (Internal Use)
ACCOUNT TYPE o Regular Savings o Better Than Free Checking
Owner’s Account (s), shall be:
o Money Market Savings o Millennium Money Market Checking o Individual o Joint
o Special Savings o PAL Line of Credit
o Basic Checking
o Interest Checking o Other
Owner (s), if any, must sign below and complete the appropriate information.
o With Pay On Death Provision / Beneficiary
ATM CARD / ACTIONLINE/ DEBIT CARD / INTERNET BANKING I/We hereby apply for: o ATM o CU Online Internet Account Access CHECKING ACCOUNT OVERDRAFT PROTECTION
o ActionLine (Telephone Banking) o MasterMoney™ Debit Card I / We agree to the terms of the Electronic Services Disclosure and Agreement.
Please cover any overdrafts on my Interest or Basic Checking Account by transferring funds from my PAL Line of Credit* and/or my account (s) in the order indicated below. (List first option as “1”, Second option as”2”, etc.) * An approved PAL Line of Credit is required. ** Overdraft protection is not available for Better Than Free Checking o Savings o Other Savings o PAL Line of Credit
SIGNATURES: Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withh olding because you have failed to report all
interest and dividends on your tax return. Signature of U.S. Person (1) Signature of U.S. Person (2) Signature of U.S. Person (3) Date Date Date
INTERNAL USE ONLY
The application for membership is approved by the following Orange County’s Credit Union Office Branch Number: Date: SEG Group Code: Primary (1) ID ChexSystems: Joint (2) ID Approval Joint (3) ID TISA Disclosure: Member Ship Officer o Yes o No Opened by: Date