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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