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WACOPSE

Membership Application

Instructions for Filling out the Application Form:

  1. Print out form FIRST, if you fill it in and then print it, nothing will appear in the boxes.

  2. Fill out your Name, Address, and other information requested.

How to Submit Your Application:

Fax: (814) 723-8738

OR

Use your regular postal service mail to:

WACOPSE Federal Credit Union
117 Pennsylvania Avenue West
Warren, PA 16535

WACOPSE Membership Application Form:

ACCOUNT TYPE

Share/Savings________________________________

Share Draft/Checking_________________________

Share Certificate/Certificate____________________

Money Market_______________________________

Other_______________________________________

Other_______________________________________

TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION

By signing below, I certify, in accordance with IRS W-9 instructions provided by the Credit Union and under penalties of perjury, that the Social Security number (SSN)/Taxpayer Identification Number (TIN) shown is my/the correct identification number and that I am NOT, unless designated below, subject to backup withholding because I have not been notified that I am subject to backup withholding as a result of a failure to report all dividends or interest, or because the IRS has notified me that I am no longer subject to backup withholding.

I am subject to backup withholding

I am not a United States Citizen or resident.

Exempt

(Complete W-8 form)

MEMBER APPLICATION AND OWNERSHIP INFORMATION

Member______________________________ Account Number______________________

Street________________________________SSN/TIN_____________________________

City/State/Zip_________________________ Driver's License No.____________________

Phone Home (_____)___________________ Date of Birth__________________________

Phone Work (_____)___________________ Mother's Maiden Name _________________

Employment________________________________________________________________

Eligibilty for Membership_____________________________________________________

AUTHORIZATION

By signing below, I/we agree to the terms and conditions of the Membership and Account Agreement, Truth-in-Savings, Rate and Fee Schedule, Funds Availabilty Policy Disclosure, if applicable and to any amendment the Credit Union makes from time to time which are incorporated herein. I/we acknowledge receipt of a copy of the Agreement and Disclosures applicable to the accounts and services requested herein. If an access card or EFT service is requested and provided, I/we agree to the terms of and acknowledge receipt of the Electronic Funds Transfer Agreement. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.


X_______________________________    X________________________________
  Signature             Date           Signature             Date

X______________________________     X________________________________ 
  Signature             Date           Signature             Date

ACCOUNT SERVICES

Payroll Deduction/Direct Deposit

Overdraft Protection (Individuals Transfer Priority Below

________________________________________________________

Other_____________________________________________

ATM Card_________________________________________

Debit Card_________________________________________

Other EFT Service___________________________________

Other______________________________________________

ACCOUNT OWNERSHIP

Designate the ownership of the accounts and responsibility for the services

Single Party

Multiple Party with Survivorship

Multiple Party without Survivorship

Joint Owner______________________________SSN/TIN__________________________

Street___________________________________ Driver's License No.________________

City/State/Zip_________________________ Date of Birth__________________________

Phone Home (_____)___________________ Mother's Maiden Name _________________

Phone Work (_____)___________________

Joint Owner______________________________SSN/TIN___________________________

Street___________________________________ Driver's License No._________________

City/State/Zip_________________________ Date of Birth___________________________

Phone Home (_____)___________________ Mother's Maiden Name _________________

Phone Work (_____)__________________

Other__________________________

See Account Authorization Card

ACCOUNT DESIGNATIONS

Payable on Death (POD)/Trust Account

All accounts

Designate specific account(s)

Beneficiary____________________________Beneficiary__________________________

Street_________________________________Street______________________________

City/State/Zip_________________________City/State/Zip_________________________

UTTMA/UGMA (as custodian for ______________________________(minor) under

the Uniform Transfers/Gifts to Minors Act) Minor's TIN/SSN ______________________

Agency/Name of Agent_____________________________

All Accounts

Designate specific account(s)___________________

FOR CREDIT UNION USE ONLY


See Account Change Card

Date of
Membership____________Opened/App'd by___________ Member Verification_______________

PIN
Request__________Credit Report_________ Check Verify________ Access Card ______________

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Copyright © 1997/98 WACOPSE Federal Credit Union
DMS 01/07/98

visitors since 1-7-98