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MEMBERSHIP
SIGN-UP INSTRUCTIONS
- Print
out and complete the Membership Application Form below.
- Include
a check or money order for your initial deposit of $5.00 payable to
Choice One Community Federal Credit Union. If you sign-up in person,
cash may also be used.
- BE SURE TO INCLUDE A COPY OF YOUR PHOTO DRIVERS LICENSE.
- Enclose
in an envelope with your initial deposit and mail - or bring it with
you to the nearest credit union location:
101
Hazle Street
Wilkes-Barre, PA 18702
Phone: (570)
823-7676
Toll-Free: (800)
610-2788
Fax: (570)
829-3937 |
992
Sherman Court
Hazleton, PA 18201
Phone: (570)
454-8005
Toll-Free: (800)
610-2788
Fax: (570)
454-8005 |
672
North River Street
Suite 107
Plains, PA 18705
Phone: (570) 823-7676
Toll-Free: (800) 610-2788
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| Account
Number______________________ Tax I.D. or Soc. Sec. No._____________________ |
| _________________________________________________________________________________ |
| (Last
Name) |
(First
Name)
|
(Middle
Name or Initial)
|
|
| Residence_________________________________________ |
P.O.
Address_________________ |
| City___________________ |
State______________________ |
Zip__________________________ |
| Home
Phone_____________________________________________________________________ |
| Employer__________________________________________ |
Tel.
No._____________________ |
| Occupation________________________________________ |
Pin
# (Optional)______________ |
| Place
of Birth__________ |
Date
of Birth_______________ |
Driver
License No.____________ |
| Mothers
Maiden Name____________________________________________________________ |
| |
| I
hereby make application for membership in Choice One Community Federal Credit
Union, and agree to conform to its bylaws and amendments thereof, copies of which
have been made available to me, and to subscribe for at least one (1) share. If
Life Savings Insurance is carried in connection with my account, I agree in consideration
of the credit union carrying such insurance, that any designation or change of
beneficiary made by me shall only be binding upon the credit union, if I have
filed with the credit union prior to my death, such designation or change of beneficiary,
in writing, signed by me, on the form supplied by the credit union, and, in the
absence of so filing a designation or change beneficiary, I agree on behalf of
myself, my heirs, etc., to indemnify and save harmless the credit union from all
loss or damage by reason of the payment of the proceeds of such insurance to such
person as the credit union records show to be entitled thereto.
We
may report information about your loan and deposit accounts to the Credit Bureaus.
Late payments, missed payments, or other defaults on your account may be reflected
in your credit report.
|
| |
| Signature__________________________________________
Date_________________________ |
|
This
application approved by the (check one):
|
(
)Board
( )Executive Committee
( )Membership Officer |
| Date_____________________________________________________________________________ |
| Signed___________________________________________________________________________ |
| Certification |
Instruction
to Signer: If you have been notified by the Internal Revenue Service (IRS) that
you are subject to backup withholding due to payee underreporting and you have
not received a notice from the IRS that the backup withholding has terminated,
you must strike out the language in clause 2 or whichever certification you sign
below.
CERTIFICATION AS TO TAXPAYER IDENTIFICATION NUMBER AND BACKUP WITHHOLDING
Under Penalties of Perjury, I certify (1) that the number shown on this form is
my correct taxpayer identification number and (2) that I am not subject to backup
withholding either because I have not been notified that I am subject to backup
withholding as a result of a failure to report all interest and dividends, or
the Internal Revenue Service (IRS) has notified me that I am no longer subject
to backup withholding and (3) that I am, unless designated below, a U.S. person
(including a U.S. resident alien).
Signature_______________________________________________ Date_____________________ |
CERTIFICATION
IF AWAITING NUMBER
Under penalties of perjury, I certify (1) that a taxpayer identification number
has not been issued to me, and that I mailed or delivered an application to receive
a taxpayer identification number to the appropriate Internal Revenue Service Center
of Social Security Administration Office (or I intend to mail or deliver an application
in the near future), and (2) that I am not subject to backup withholding as a
result of a failure to report a;ll interest or dividends, or the Internal revenue
Service (IRS) has notified me that I am no longer subject to backup withholding.
I understand that if I do not provide a taxpayer identification number to the
Credit Union within 60 days, the credit union is required to withhold 20 percent
of all reportable payments thereafter made to me until I provide the number.
Signature________________________________________________Date_____________________
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JOINT
SHARE ACCOUNT AGREEMENT (*Not Transferable)
The Choice One Community Federal Credit Union is hereby authorized to recognize
any of the signatures subscribed hereto in payment of funds or the transaction
of any business for this account. The joint owners of this account, hereby agree
with each other and with said Credit Union that all sums now paid in on shares,
or heretofore or hereafter paid in on shares by any or all of said joint owners
to their credit as such joint owners with all accumulations thereon, are and shall
be owned by them jointly, with right of survivorship and be subject to the withdrawal
or receipt of any of them, and payment to any them or the survivor or survivors
shall be valid and discharge said Credit Union from any liability for such payment.
The joint owners also agree to the terms and conditions of the account as established
by the Credit Union from time to time.Any or all of said joint owners may pledge
all or any part of the shares in this account as collateral security to a loan
or loans from this Credit Union. The right or authority of the Credit Union under
this agreement shall not be changed or terminated by said owners, or any of them
except by written notice to said Credit Union which shall not affect transactions
theretofore made.(The signature on the first line should be the same as signed
on the front of card. ) |
| Joint
Account No. _________________________________________Date____________________ |
|
Soc.
Sec. Or
Tax I.D. No.
______________________
______________________
|
Joint
Owners
(each must sign)
___________________________
___________________________
|
Date
of Birth
____________________________
____________________________
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*As
defined in 12 CPR Part 204 |
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Me More!
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Regular Share Savings Accounts