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Membership Application Please print this form, fill it out and fax to 412-653-5076 |
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Membership Application Please print this form, fill it out and fax to 412-653-5076 |
| General Information: | |
Will there be a co-applicant on this application?  No Yes, 1 co-applicant Yes, 2 co-applicants |
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| Membership Eligibility: | |
| Employer |
Employer Name: |
| Family
Member |
Family Name: |
| Community |
Community Name: |
| Primary Applicant: | |
| Last Name: | Middle Name: |
| First Name: | Social Security Number (TIN): |
| Date of Birth: | Home Phone Number: |
| Work Phone Number: | Other Phone Number: |
| Email Address: | Mother's Maiden Name |
| I certify that: The TIN is correct and I ( am / am not ) subject to back-up withholding (Circle One) and I am a U.S. Person (including a U.S. Resident Alien). |
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| Drivers License #: | Drivers License State: |
| Drivers License Expiration Date: | |
| Home Address (not P.O. Box) | |
| Address 1: | |
| Address 2: | |
| City: | State, Zip: |
| Time at Current Residence: | Residence Type: Own Rent Other: |
| Mailing Address (if different) | |
| Address 1: | |
| Address 2: | |
| City: | State, Zip: |
| Employment History | |
| Present Employer Name: | Employer Phone Number: |
| Employer's Address 1: | |
| Employer's Address 2: | |
| City: | State, Zip: |
| Job Title: | Job Start Date: |
| Co-Applicant 1: | |
| Last Name: | Middle Name: |
| First Name: | Social Security Number (TIN): |
| Date of Birth: | Home Phone Number: |
| Work Phone Number: | Other Phone Number: |
| Email Address: | Mother's Maiden Name |
| I certify that: The TIN is correct and I ( am / am not ) subject to back-up withholding (Circle One) and I am a U.S. Person (including a U.S. Resident Alien). |
|
| Drivers License #: | Drivers License State: |
| Drivers License Expiration Date: | |
| Home Address (not P.O. Box) | |
| Address 1: | |
| Address 2: | |
| City: | State, Zip: |
| Time at Current Residence: | Residence Type: Own Rent Other: |
| Mailing Address (if different) | |
| Address 1: | |
| Address 2: | |
| City: | State, Zip: |
| Employment History | |
| Present Employer Name: | Employer Phone Number: |
| Employer's Address 1: | |
| Employer's Address 2: | |
| City: | State, Zip: |
| Job Title: | Job Start Date: |
| Co-Applicant 2: | |
| Last Name: | Middle Name: |
| First Name: | Social Security Number (TIN): |
| Date of Birth: | Home Phone Number: |
| Work Phone Number: | Other Phone Number: |
| Email Address: | Mother's Maiden Name |
| I certify that: The TIN is correct and I ( am / am not ) subject to back-up withholding (Circle One) and I am a U.S. Person (including a U.S. Resident Alien). |
|
| Drivers License #: | Drivers License State: |
| Drivers License Expiration Date: | |
| Home Address (not P.O. Box) | |
| Address 1: | |
| Address 2: | |
| City: | State, Zip: |
| Time at Current Residence: | Residence Type: Own Rent Other: |
| Mailing Address (if different) | |
| Address 1: | |
| Address 2: | |
| City: | State, Zip: |
| Employment History | |
| Present Employer Name: | Employer Phone Number: |
| Employer's Address 1: | |
| Employer's Address 2: | |
| City: | State, Zip: |
| Job Title: | Job Start Date: |
| References | |
| Nearest Relative Not Living With You | |
| Last Name: | First Name: |
| Relationship: | Phone Number: |
| 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: |
| Signature | |
The Internal Revenue Service does not require your consent to any provision of this contract other than the certifications required to avoid backup withholding. 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
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. |
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| Signature: | Date: |