Artesian City Federal Credit Union

SIGNATURE CARD

Artesian City Federal Credit Union	ACCOUNT TYPE
		Share/Savings	Share Draft/Checking
		Christmas Club	Other
		Other	Other

MEMBER APPLICATION AND INFORMATION

Member	Street

Account Owner	City

SSN/TIN	State	Zip

Account No.	Driver's Lic. No	State

Mother's Maiden Name	Date of Birth

Home Phone	Work Phone

Eligibility for Membership

ACCOUNT OWNERSHIOP

JOINT OWNER (Multiple Party with Survivorship)

Street

Account Owner

City

SSN/TIN

State

Zip

Account No.

Driver's Lic. No

State

Mother's Maiden Name

Date of Birth

Home Phone

Work Phone

FOR CREDIT UNION USE ONLY

Date of Membership	Opened/App'd By	Member Verification
I/A Activated	Credit Report	Check Verify	I/D Verify

ACCOUNT SERVICES COMPLETED
	Payroll Deduction/Direct Deposit	ATM Card
	Overdraft Protection	Other EFT Service
	Voice Response	Other

BENEFICIARY DESIGNATIONS

PAYABLE ON DEATH (POD) ACCOUNT

Payee/Beneficiary		Payee/Beneficiary
Street		Street
City		City
State/Zip		State/Zip

AUTHORIZATION

     By signing below I/we make application for membership in Artesian City Federal Credit Union (Credit Union) and agree that my accounts with the Credit Union are and shall be governed by the terms and conditions of the Membership and Account Agreement, Truth-in-Savings Rate and Fee Schedule, Funds Availability Policy Disclosure, Overdraft Protection Agreement (if applicable), and if an Access Card or EFT Service is requested, I/we agree to the terms of and acknowledge receipt of the Electronic Funds Transfer Agreement. In addition I agree to be bound by all of the Credit Union's by-laws and amendments thereto which may be adopted from time to time by the Credit Union. I hereby authorize the Credit Union to obtain credit reports and investigations as it may deem necessary to establish my accounts and loans. I/we acknowledge receipt of a copy of the Agreements and Disclosures applicable to the accounts and services requested herein.
      Under penalties of perjury, I certify that: (1) The number shown on this form is the correct security number/taxpayer identification number (or I am waiting on the receipt of a number) and (2) I am not subject to backup withholding (unless indicated below) because: (a) I am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding as a failure to report all interest or dividends or (c) the IRS has notified me that I am no longer subject to backup withholding.
       The Internal Revenue Service does not require your consent to any provision of this document other that the certifications required to avoid backup withholding.

	I am subject to backup withholding
	I am not a United States citizen or resident (complete W-8 Form)

Member's Signature ____________________________________

Date ________________________

Joint Owner's Signature _________________________________

Date________________________

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