Member Application

Account Card, Membership Account and Services Application

"*" indicates required fields

Member Application

Account Card, Membership Account and Services Application

Type*

Savings / Prime Share

Checking

Certificate

Club Account

IRA Savings

Applicant Details

This is the description of your section break.

Applicant Name*

Date of Birth*

Primary Phone*

Phone

SSN*

Mother's Maiden Name*

Email*

Valid Drivers License or State ID

Type of ID*

State*

ID#*

Date Issued*

Expiry Date*

Address

Street Address*

Address Line 2

City*

Postal / Zip Code*

State / Province / Region*

Country*

Occupation*

Employer Address

Name*

Employer Phone Number*

Street Address

Address Line 2

Postal / Zip Code

City

State / Province / Region

Country

References

Name*

Address

Street address*

City*

Postal / Zip Code*

Phone*

Relationship

State / Province / Region

Country

References

Name*

Address

Street address*

City*

Postal / Zip Code*

Phone*

Relationship*

State / Province / Region

Country

Joint Applicant Details

Add a joint applicate

Applicant Name*

Date of Birth*

SSN*

Mother's Maiden Name*

Drivers Licence of Other Government ID

State*

ID#*

Date Issued*

Expiry Date*

Address

Street Address*

Address Line 2

City*

Postal / Zip Code*

State / Province / Region*

Country

Occupation*

Employer Address

Name*

Employer Phone Number*

Street Address

Address Line 2

City

Postal / Zip Code

State / Province / Region

Country

References

Name*

Address

Street address*

City*

Postal / Zip Code*

Phone*

Relationship*

State / Province / Region*

Country

References

Name*

Address

Street address*

City*

Postal / Zip Code*

Phone*

Relationship*

State / Province / Region*

Country

Authorized Signatures

By signing up below you acknowledge and agree to all terms, disclosures, and representations by you made herein and on your online applications.

Member - Draw your signature into the box below.*

Date*

Co-Member - Draw your signature into the box below.*

Date*

I understand and agree that the Patriot's Act of 2001 obligates all persons seeking to open an account to fully comply with the identity verification requirements of the Bank Secrecy Act, as amended from time to time. Transactions to/from any accounts may be limited until ID verification of all persons is completed.

I certify (1) that the number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and (2) I am not subject to backup withholding because: (a) I am exempt from back-up withholding, or (b) I have not been notified by the Internal revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding and (3) I am a U.S. person (including a U.S. resident alien.Certification Instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return..

Signatures, Consents And Agreements:

Each applicant, authorized user or other party signing this Card, (together herein referred to as “applicant(s)”) hereby makes application for the account(s)/services and/or membership as indicated and agrees to conform to the Bylaws, as may be amended, of Latitude 32 Federal Credit Union ("Credit Union"). Applicants certify the signature(s) on this card apply to all accounts designated above; and all information provided is true and correct. Applicants also acknowledge receipt and agree to be bound by any terms and conditions in this card, and in the Accounts & Services of the Credit Union Booklet, Truth-in-Savings Act Rate and Fee Schedule, and any Special Account or other separate Account Service Applications or Agreements as amended from time to time, which are incorporated herein by reference. Each applicant consents that the Credit Union may undertake to verify their eligibility for any account(s) and service(s) now and in the future. In addition, all applicants authorize us to make inquiry to determine your employment history and to obtain information concerning any accounts with other institutions and your credit history, including any credit reports. Applicants specifically consent that the Credit Union may report information concerning their account(s)services to others; and that we may provide the reasons should we determine you to be ineligible for any services or to be an authorized person/user to the other applicants. All present and future deposits to the account(s) designated above secure payment of any account owner's obligations to the Credit Union. If any representative capacity is indicated on the reverse side, the Credit Union shall provide all statements, notices and other information only to the person designated as having authority (e.g., a “trustee’).

Account Ownership (Applicable If Joint Ownership Is Designated On Reverse Side):

The owners intend to and do hereby create a joint tenancy with rights of survivorship; and specifically agree to the terms set forth in the Membership Agreement including but not limited to the Credit Union’s rights to pay or transfer any deposits by the order of any owner, to accept a pledge of all sums deposited now or in the future from any owner, and to enforce any legal or contractual lien rights as to any owner’s obligations.

Phone

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Member Application