The CREDIT UNION for Robertson County

MEMBERSHIP APPLICATION

To use this form:
Complete the form on screen, print out and fax, mail or bring to our Main Office.

Account Type
	Share/Savings		Money Market
	Share Draft/Checking		Other
	Share Certificate/Certificate		Other

Member Application and Ownership Information
Account No.
Member
Physical Address (required)
Street
City/State/Zip
Mailing Address (if different than physical address)
Street
City/State/Zip
Home Phone
Work Phone
Employment
SSN No.
Driver's Lic.  No.
Date of Birth
Mother's Maiden  Name
Eligibility for  Membership

Account Services
	Payroll Deduction/Direct Deposit		ATM Card
	Overdraft Protection (indicate transfer priority below)		Debit Card
			Other EFT Service
	Other		Other

Account Ownership
Designate the ownership of the accounts and responsibility for the services requested.
		Single Party
		Multiple Party with Survivorship
		Multiple Party without Survivorship
Joint Owner One
Street
City/State/Zip
Home Phone
Work Phone
SSN No.
Driver's Lic.  No.
Date of Birth
Mother's  Maiden Name
Joint Owner Two
Street
City/State/Zip
Home Phone
Work Phone
SSN No.
Driver's Lic.  No.
Date of Birth
Mother's  Maiden Name

ACCOUNTS OPENED VIA INTERNET require that your signature be notarized. Please sign in the presence of a notary. Copies of two forms of Identification (one government issued photo ID such as driver’s license, military ID, etc.) and one other form of ID (such as Social Security Card, Voters Registration, etc.) must also be obtained and certified by the notary to be true copies of the original documents. Proof of address (such as utility bill, payroll stub showing current address, etc.) is required if address is different than what appears on your identification.

X_______________________________________   Primary Signature and Date

X_______________________________________   Joint Owner 1 Signature and Date

X_______________________________________   Joint Owner 2 Signature and Date

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the CREDIT UNION for Robertson County.
All Rights Reserved.