LM Federal Credit Union

Membership Application

ACCOUNT TYPE (check one only)

Share/Savings
Checking
Certificate
Club
IRA Acct
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 ID number (TIN) shown is my correct 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 dividends or interest, or because the IRS has notified me that I am no longer subject to backup withholding.

PRIMARY MEMBER APPLICATION AND INFORMATION

Full Name:

Soc. Sec. #

Address:

Apt. #

City:

State:

Zip:

E-Mail:

Employer/Division Employee #

Birth Date:

Drivers License #/State:

Day Phone:

Night Phone:

Membership Eligibility by:

Fill out one of the two text boxes below based on your answer

Employer:

Family Member, Name:

AUTHORIZATION

By signing below, I/we agree to the terms and conditions of the Membership and Account Agreement, Truth-In-Savings Rate & Fee Schedule, Funds Availability 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 Agreements and Disclosures applicable to the accounts and services requested herein. If an access card or EFT service is requested or provided, I/we agree to the terms of and acknowledge receipt of the Electronic Funds Transfer Agreement. I/we authorize the Credit Union to obtain a consumer credit report in order to evaluate my request for a checking account and/or access card connection with this application and for any update, renewal or reconsideration required. You may request the name, address and phone number of any credit bureau from which the Credit Union received a consumer report. 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
Primary Member Signature/Date	Joint Owner Signature/Date

X	X
Joint Owner Signature/Date	Joint Owner Signature/Date

OTHER SERVICES AUTHORIZATION

Checking Accounts: Overdraft Protection from:

Certificate Accounts: Pay dividends to:

ACCOUNT OWNERSHIP SELECTION/JOINT OWNER LIST

# of signatures required:

Joint Account Owners: (DON?T LIST THE PRIMARY OWNER BELOW)

PRINT NAME BELOW	SOC. SEC. #	BIRTH DATE	PHONE #

ACCOUNT DESIGNATIONS

Payable on Death (P.O.D.)

Beneficiary	Beneficiary:

Address:	Address:

UTTMA (as custodian for (minor) under the Uniform Transfers to Minors Act). Minor?s Soc. Sec. #

FOR CREDIT UNION USE ONLY

Membership Officer Approval:	Date

We will begin processing this request immediately after receiving it. You may print it out, sign it and mail, fax or drop it off at the credit union. Or, if you would like to e-mail it, a form requesting your signature will be forwarded to you soon to complete the membership process. Thank you.

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