Fill - Free fillable Form 8605225388: MEMBER APPLICATION/ACCOUNT CARD (Northwestern Connecticut Community College) PDF form

This application approved by the Board, Executive Committee or Membership Officer

Signed___________________________________________________ Date______________ MIP: OFAC________ ID Verify ___________ Date__________

Secretary, Executive Committee Member or Membership Officer

84WadsworthStreet

Hartford,CT06106

860‐522‐5388

www.CSECreditUnion.com

Completeformandreturnto:

MEMBER APPLICATION/ACCOUNT CARD

MembershipEligibility

 StateemployeesmustprovidearecentStatepaystuboravalidCTStateEmployeeID.

 Retireesmustprovidestateagencyandretirementdate.

 Immediatefamilymembersmustprovidemember’snameandrelationship.

MEMBERINFORMATION

PrimaryOw

ner: SSN/TIN:

StreetAdd

ress:

Driver’sLic.#:

State/Exp:

City/

State/Zip: DateofBirth:

HomePh

one:

WorkPhone: CellPhone:

MembershipEligib

ility: PersonalE‐mail:

Wor

kNameandAddress: Occupation:

BENEFICIARYDESIGNATIONS-Must be a “natural person” (No trusts, charities or organizations)

Name: DateofBi

rth: FullAddress:

Name: DateofBi

rth: FullAddress:

ACCOUNTOWNERSHIP/JOINTSHAREACCOUNTAGREEMENT

JointOw

ner: SSN/TIN:

StreetAdd

ress:

Driver’sLic.#:

State/Exp:

City/

State/Zip: DateofBirth:

HomePh

one:

CellPhone: Occupation:

JointOw

ner: SSN/TIN:

StreetAdd

ress:

Driver’sLic.#:

State/Exp:

City/

State/Zip: DateofBirth:

HomePh

one:

CellPhone: Occupation:



TheConnecticutStateEmployeesCreditUnion,Inc.isherebyauthorizedtorecognizeanyofthesignaturessubscribedheretointhepaymentoffundsorthetransactionofany

businessforthisaccount.TheprimaryownerandthejointownersofthisaccountherebyagreewitheachotherandwithsaidCreditUnionthatallsumsnowpaidinonshares,or

heretoforeorhereafterpaidinonsharesbyanyorallofsaidjointownerswithallaccumulationsthereonareandshallbeownedbythemjointly,withrightofsurvivorshipandbe

subjecttothewithdrawalorreceiptofanyofthem,andpaymenttoanyofthemorthesurvivororsurvivorsshallbevalidanddischargesaidCreditUnionfromanyliabilityforsuch

payment.Anyorallofsaidjointownersmaypledgealloranypartofthesharesinthisaccountascollateralsecuritytoaloanorloans.TherightorauthorityoftheCreditUnion

underthisagreementshallnotbechangedorterminatedbysaidowners,oranyofthemexceptbywrittennoticetosaidCreditUnionwhichshallnotaffecttransactionstheretofore

made.TheCreditUnionisauthorizedtoverifyinformationandcredithistorywithconsumerreportingagencies.Furthermore,onlythePrimaryOwnermayclosetheshareaccount.



JointOwnerSignature Date JointOwne rSignature Date



ACKNOWLEDGMENT

IherebymakeapplicationformembershipintheConnecticutStateEmployeesCreditUnion,Inc.andagreetoconformtoitslawsandamendmentsthereofandsubscribeforatleast

oneshare.IcertifythatallinformationcontainedinthisApplicationistrueandaccurate.Iagreetoabidebythetermsoutlinedinthedisclosuresformembership,includingbutnot

limitedtotheJointShareAccountAgreement,Truth‐in‐SavingsDisclosure,andFundsAvailabilityPolicyDisclosure.Ialsocertify,underpenaltiesofperjury,thatthesocialsecurity

numberenteredaboveiscorrectandthatIamnotsubjecttobackupwithholdingunderprovisionsofsections3406(a)(1)(c)oftheInternalRevenueCode.



PrimaryOwnerSignature Date

(Creditunionuseonly)

Teller#____________Member#____________________________

DLVe

rify_______________________________________________

IDt

ype/#_______________________________________________

Update_

______________________________________________

Includeanopeningdepositof$25toestablishyourcreditunionmembership.

Ifapplyinginperson,bringtwoformsofvalidID.

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Form 8605225388: MEMBER APPLICATIONACCOUNT CARD (Northwestern Connecticut Community College)

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