APPLICATION PURPOSE
r New Member r Add Service r Add Joint Owner r Change
Account Number Type
__________________________ ___________
__________________________ ___________
__________________________ ___________
__________________________ ___________
__________________________ ___________
__________________________ ___________
__________________________________
READ THIS IMPORTANT INFORMATION BEFORE SIGNING - If you have any questions, please contact us before signing.
AUTHORIZED SIGNERS ONLY - Unless otherwise a member, to the Board of Directors, on behalf of the member, I hereby: (1) apply for membership;
(2) submit the $5 for one share in the credit union; and (3) request a Member Share account be opened to deposit the member’s $5 share amount. I
attest that the member is the sole owner of any account opened with this application. Further, by signing below, I agree that all accounts, services and/or
features opened for or provided to the member, are subject to all terms and conditions as stated in the: (1) Membership Rules and Regulations Disclosure
(which include Rules and Regulations, Funds Availability Disclosure, and Electronic Funds Transfer Disclosure); (2) Rate Disclosure; (3) Account and Fee
Disclosure; and; (4) any other disclosure that applies to a specic product, service or feature. I acknowledge VACU provided the aforementioned items/
disclosures and I agree to VACU’s right to amend any of these items/disclosures from time to time. In addition, I request that VACU issue a QuikLine PIN
(personal identication number) to me for telephone access to allowable accounts and services. I attest that I am legally authorized to act on behalf on the
designated member. I understand and agree that VACU may allow any Authorized Signer designated on this application to singularly act on behalf of the
member and that VACU accepts no duciary responsibility other than as a depository of funds. I agree to notify VACU immediately of any changes that
may impact this member and the member’s relationship with VACU, including but are not limited to: a change in address, removal of an Authorized signer,
etc. My signature below is my continuing authorization for VACU to follow my electronic, written or verbal instructions and I agree that this authorization will
remain in effect unless VACU receives written and acceptable instructions to the contrary.
IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT - Federal law requires all nancial institutions to obtain, verify
and record information that identies each person who opens an account. When you open an account, we may ask for your name, address, date of birth
and other information that allows us to identify you. We may also ask to see your driver’s license or other identifying documents.
TAX CERTIFICATION: under penalties of perjury, by signing below I certify that: (1) the Social Security or Tax ID Number listed for the Member is the
correct number for tax reporting purposes; (2) the member is not subject to backup withholding under the provisions of the IRS Code; (3) the member
is a U.S. person or U.S. resident alien; and (4) all information provided is correct. Instruction to Signer: if you have been notied by the IRS that the
member is subject to backup withholding due to notied payee underreporting and you have not been notied that the backup withholding is terminated,
you should strike out the language in clause 2 above. Cross out item 3 and complete a W-8BEN if the member is not U.S. person.
The IRS does not require your consent to any provision of this document other than certication required to avoid backup withholding.
_____________________________________________________ ______________________
Signature of Authorized Signer #1 Date CIF #
_____________________________________________________ ______________________
Signature of Authorized Signer #2 (if applicable) Date CIF #
_____________________
Minor’s CIF #
FOR CHECKING ACCOUNTS ONLY
r CHECK ORDER FORM - initial box of VACU specialty checks.
Your initial check order will be one box of VACU specialty checks printed with
your name, address and other owner’s name unless changes are noted here:
_____________________________________________________________
_____________________________________________________________
Check numbers will start with 101 unless noted here: __________________
r OVERDRAFT PROTECTION List the accounts in the order
in which you want available funds to be transferred.
1. ______________________ ___________________________
2. ______________________ ___________________________
3. _____________________ ___________________________
Account Type Account Number
OTHER MEMBERSHIP & ACCOUNT APPLICATION
Page 2 of 2
Continued
AUTHORIZED SIGNER #2 / CUSTODIAN INFORMATION (if applicable) - application may be denied if all elds are not completed
Legal Name _____________________________________________________________________ DOB (MM/DD/YYYY) _____________________________
SSN/ITIN/EIN _______________________________________ E-mail Address _______________________________________________________________
Home Phone ( ) ______________________ Cell Phone ( ) __________________________ Work Phone ( ) ____________________
Are you a: (check one) r US Citizen r Resident Alien r Non-resident Alien Country of Citizenship ___________________________________________
Physical Address __________________________________________________________________ City, State ______________________ Zip ____________
Mailing Address ___________________________________________________________________ City, State ______________________ Zip ____________
Occupation ___________________________________________________ Employer _________________________________________________________
Are you a college student? No r Yes r School you attend _______________________________________________________________________________
FOR CREDIT UNION USE ONLY:
Date ______________________
Branch # __________________
Employee # _______________
FOR BUSINESS DEVELOPMENT USE ONLY:
ID Type _______ Issue Place ____ Issue Date _________________
Exp. Date _________________ ID # __________________________
