Application for Certificate of Deposit Account

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					                                     Application for Certificate of Deposit Account
  Form Instructions:
  Complete all applicable areas on the form and sign and date in the signature area. Print and mail the completed form to Delta Community Credit
  Union ATTN: Member Service. P.O. Box 20541, Atlanta, GA 30320-2541, or fax to 404-677-4802. Upon receipt of this form and your check or
  transfer fund instructions, the Credit Union will open your Certificate of Deposit Account and your account disclosure documents will be mailed to you.
Member Information

________________________________________________________________                    _________________            ________________
 First Name             MI    Last Name                                             Social Security Number       CU Account #

________________________________________________________________________                       ______________________________________
 Street                 City                     State     ZIP                                  Phone Number
Joint Owner Information

_______________________________________________________________                      __________       ___________________           ______
 Name                                       Social Security Number                   Date of Birth    Driver’s License/State ID #   State

________________________________________________________________________                       _______________________________________
 Street                 City                     State     ZIP                                  Phone Number

_______________________________________________________________                      __________       ___________________           _______
 Name                                       Social Security Number                   Date of Birth    Driver’s License/State ID #    State

________________________________________________________________________                       _______________________________________
 Street                 City                     State     ZIP                                  Phone Number

_______________________________________________________________                      __________       ___________________           _______
 Name                                       Social Security Number                   Date of Birth    Driver’s License/State ID #   State

________________________________________________________________________                       ______________________________________
 Street                 City                     State       ZIP                                Phone Number
Payable on Death Payee (Beneficiary) Information (Cannot be a Joint Owner)

__________________________________________________________________                                   _________________________________
 Name                                                                                                Social Security Number

__________________________________________________________________                                   _________________________________
 Name                                                                                                Social Security Number
Certificate of Deposit Account Options
Please select the term of your deposit                                    Renewal Information

    6 Month Term          12 Month Term                                      Automatically renew for another term at maturity.
   24 Month Term          36 Month Term
   60 Month Term                                                             Transfer funds to Account #__________- ID_______ at maturity.

Opening Deposit Instructions                                              Dividend Payment Options
Opening Deposit: $______________ (Minimum is $1,000)
                                                                             Compound monthly
   Check enclosed (if not from Delta Community CU funds)
                                                                             Transfer to Account ID#_______
   Transfer funds from my Account #_______________ ID ______

I hereby authorize Delta Community Credit Union to open the above certificate of deposit account.
______________________________________________________________                                          _____________________
Member Signature                                                                                                 Date

______________________________________________________________                                          _____________________
Joint Owner Signature                                                                                            Date
________________________________________________________________                                        _____________________
Joint Owner Signature                                                                                            Date
________________________________________________________________                                        _____________________
Joint Owner Signature                                                                                            Date