<% if Request.ServerVariables("HTTPS") = "off" Then Response.Redirect("https://" & Request.ServerVariables("HTTP_HOST") & Request.ServerVariables("URL")) End if %> Checking/Savings Account Application - fax to 412-653-5076

Checking/Savings Account Application 
Please print this form, fill it out and fax to 412-653-5076
   
 Account Information
 Will there be a co-applicant on this application?    Yes    No
 I am interested in:
    Checking Account
        Type of Checking Account:  ____________________________________________
        Initial Deposit Amount:  $_______________________________________________
        Source of Deposit:
           Transfer from a current account.   Account Number:  _____________________
           I will transfer funds from another institution.
           I will mail a check/money order.
           Other.   (please describe)  _________________________________________
    Savings Account
        Type of Savings Account:  _____________________________________________
        Initial Deposit Amount:  $_______________________________________________
        Source of Deposit:
           Transfer from a current account.   Account Number:  _____________________
           I will transfer funds from another institution.
           I will mail a check/money order.
           Other.   (please describe)  _________________________________________
    Other Account
        Description:  ________________________________________________________
        Initial Deposit Amount:  $_______________________________________________
        Source of Deposit:
           Transfer from a current account.   Account Number:  _____________________
           I will transfer funds from another institution.
           I will mail a check/money order.
           Other.   (please describe)  _________________________________________
 I am also interested in:
    ATM Card
    ATM and Check/Debit Card
    Credit Card
    Direct Deposit
    Other   (please describe)  ______________________________________________
 Primary Applicant
 Last Name:  Member Number:
 First Name:  Middle Name:
 Social Security Number (TIN):  Date of Birth:
 Home Phone Number:  Work Phone Number:
 Other Phone Number:  Email Address:
 Drivers License #:  Drivers License State:
 Mother's Maiden Name:  Present Employer Name:
 Home Address
 Address 1: 
 Address 2: 
 City:  State, Zip:
 Co-Applicant
 Last Name:  Member Number:
 First Name:  Middle Name:
 Social Security Number (TIN):  Date of Birth:
 Home Phone Number:  Work Phone Number:
 Other Phone Number:  Email Address:
 Drivers License #:  Drivers License State:
 Mother's Maiden Name:  Present Employer Name:
 Home Address
 Address 1: 
 Address 2: 
 City:  State, Zip:
 Additional Information
 How would you prefer to be contacted?
  Home Phone
  Work Phone
  Other Phone
  Email Address
  Other:
Special Instructions/Comments:
 
 
 
 Signatures

In order to comply with the U.S.A. Patriot Act, the United Community Federal Credit Union is required to verify the identity the members applying for and opening new accounts/services or adding signatories to existing accounts/services with the credit union. Information that we are required to obtain includes:Name

  • Mailing Address
  • Residence Address (if different)
  • Social Security Number or Tax Identification Number
  • Date of Birth
  • Copy of government issued photo ID (such as driver's license, passport, Student ID, State issued ID, etc.)

Additional data or identification, as required under the U.S.A. Patriot Act, may also be gathered depending on the type of account applied for or opened. 

Data on existing members will be gathered as they open or use additional services offered by the credit union or add signatories on accounts. 

The U.S.A. Patriot Act requires the credit union to maintain records of the identification verification and update the information. 

Confidentiality of this information will be maintained as required under the Privacy Act and all other applicable laws and regulations.
 Primary Applicant Signature:  Date:        
 Co-Applicant Signature:  Date: