 |
 |
| (please print out and complete this form per instructions below) |
 |
Credit Union Use Only
FSUCU Member #____________
Initials of Employee Opening Account ____________
Initials of Referring Employee____________
|
|
After your application has been received by the credit union we will mail you the necessary Truth in Savings Act disclosures within
20 calendar days. In addition, the Reg E disclosure will be mailed to you before any electronic fund transfer services are started.
|
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.
|
Membership Eligibility (please choose the one most appropriate affiliation)
- FSU Faculty/Staff ___
- FSU Student ___
- FSU graduate who lives and/or works in Franklin, Gadsden, Jefferson, Liberty, Leon, Wakulla or Bay County ___
- Employed by business that conducts business with FSU - Business Name _________________________
- Member or employee of FSU organization - Organization ____________________
- Family member of person eligible for membership - Name of eligible person ____________________
- Employee or resident of HarborChase Senior Living Community ___
- FSUCU Employee ___
- Live and/or work in Leon, Gadsden or Wakulla County ___
|
Account Type
Share/Savings ___
Money Mint ___ Share Draft/Checking ___ Certificate of Deposit ___ Other ______
|
TIN Certification and Backup Withholding Information
Under penalty of perjury, you certify (1) that the SSN/TIN number shown on this form is your correct taxpayer identification number (or you are
waiting for a number to be issued to you); (2) you are not subject to backup withholding because (A) you are exempt from backup withholding or
(B) you have not been notified by the IRS that you subject to backup withholding as a result of a failure to report all interest or dividends,
or (C) the IRS has notified you that you are no longer subject to backup withholding; and (3) you are a U.S. citizen or other U.S. person.
YOU MUST SIGN HERE!____________________________________________ (signature)
|
Member Application and Information |
| Full Name: |
SSN/TIN: |
| Address: |
Date of Birth:
|
Employment: |
Home Phone:
|
Work Phone: |
| ID Type & Number: |
ID State of Issue: |
ID Issue Date: |
| ID Expiration Date: |
Mother's Maiden Name:
|
Email Address: |
Account Ownership (complete only for multiple owners) |
| Full Name: |
SSN/TIN: |
| Address: |
Date of Birth:
|
Employment: |
Home Phone:
|
Work Phone: |
| ID Type & Number: |
ID State of Issue: |
ID Issue Date: |
| ID Expiration Date: |
Mother's Maiden Name:
|
Email Address: |
Optional Special Account Designations: |
| □ Payable on Death |
Beneficiary 1:
|
Address: |
Beneficiary 2:
|
Address: |
Other Services: |
|
□ Personal Branch Internet Banking Service (PCU). Selecting this option will allow you unlimited, no-charge access to
your accounts through our website. You must have a checking account to be eligible. Your Personal Identification Number (PIN) must be between
4 and 10 alphanumeric characters.
Please indicate your PIN here:_____________________________
Primary Account owner sign here:_____________________________________________
|
|
□ Debit Card.
Primary account owner sign here:
__________________________________
|
□ Overdraft Protection. |
|
□ E-Statements.
Selecting this option means you consent and agree that we may provide all disclosures, agreements, contracts, periodic statements, receipts,
modifications, amendments, and all other evidence of our transactions with you or on your behalf electronically. After this signed application
has been received by the credit union, the Electronic Records Consent Form will be sent to you within 20 calendar days.
Please indicate the email address where you wish to receive notification of electronic postings:______________________________
Primary Account owner sign here:_____________________________________________
|
Account Usage Information |
|
What is the purpose of this account? (Please be specific: Will it be a primary checking account? Auxiliary? Vacation Savings?)_________________________________________________
Is the physical address you provided on the front the place you reside? Yes____ NO____
Is the physical address you provided on the front a mailbox storefront? Yes____ NO____
*If you answered Yes to providing a mailbox storefront address, enter your physical address here:_________________________________________________________________________________
Please tell us the level of activity you anticipate with this account:
WITHDRAWALS including cash, debit card, ATM, ACH, etc: Number per month______________ Total amount per month______________
DEPOSITS including mail, teller, direct deposit, shared branches, etc: Number per month______________ Total amount per month______________
Do you anticipate sending wires from this account? Yes____ NO____
If yes, how frequently? ____________ per _____________
Do you anticipate receiving wires into this account? Yes____ NO____
If yes, how frequently? ____________ per _____________
|
Authorization: |
|
This form must be notarized and a copy of a driver's license is necessary before processing the above information. $15 must accompany
this form - $10 is a membership fee, and $5 is deposited into a share account as your share of ownership. Additionally, if you wish to open a
checking account at this time, please include a $25 initial checking deposit.. 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
Disclosures applicable to the accounts and services requested herein. If a debit 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 authorized the credit union to check my credit and employment
history and obtain all information and documentation it deems necessary to confirm my eligibility for credit union products and services. The
Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup
withholding.
|
You may mail this completed form to:
FSU Credit Union, PO Box 182499, Tallahassee, FL, 32318-0022
|
Primary Signature:________________________________________________________
Date:________________________________
|
Joint Account Signature:___________________________________________________
Date:________________________________
|
|
 Click for disclosures |
Federally Insured by NCUA
