| SIGNATURE
CARD |
PLATINUM
FEDERAL
CREDIT UNION |
ACCOUNT
TYPE
|
| |
Share/Savings |
|
Other____________ |
|
| MEMBER
APPLICATION AND INFORMATION |
| Member_______________________________ |
Account No._____________________ |
| Account Owner_________________________ |
SSN/TIN________________________ |
| Street_________________________________ |
Driver's Lic.
No__________________ |
| City__________________________________ |
State___________________________ |
| State/Zip______________________________ |
Date of Birth_____________________ |
| Phone Home ( )______________Work( )_______________ |
Mother's Maiden
Name_____________ |
| Eligibility
for Membership__________________________________________________________________________ |
|
| ACCOUNT
OWNERSHIP |
| |
JOINT
OWNER (Multiple Party with Survivorship) |
|
| Account Owner_______________________ |
SSN/TIN______________________ |
| Street_______________________________ |
Driver's
Lic. No________________ |
| City________________________________ |
State_________________________ |
| State/Zip____________________________ |
Date of Birth__________________ |
| Phone Home ( )_____________
Work ( )_____________ |
Mother's Maiden
Name__________ |
|
| FOR
CREDIT UNION USE ONLY |
| Date
of Membership_________ |
Opened/App'd
By_______ |
Member
Verification______________ |
| I/A
Activated______________ |
Credit
Report___________ |
Check
Verify______ |
I/D
Verify_______ |
| ACCOUNT
SERVICES COMPLETED |
| |
Payroll
Deduction/Direct Deposit |
|
ATM
Card |
| |
Overdraft
Protection |
|
Other
EFT Service___________________ |
| |
Voice
Response |
|
Other______________________________ |
|
| BENEFICIARY
DESIGNATIONS |
| |
PAYABLE
ON DEATH (POD) ACCOUNT |
Payee/Beneficiary ______________________ |
Payee/Beneficiary ______________________ |
| Street
________________________________ |
Street
________________________________ |
| City
_________________________________ |
City
__________________________________ |
| State/Zip
_____________________________ |
State/Zip
_____________________________ |
|
| AUTHORIZATION |
By
signing below I/we make application for membership in Platinum Federal
Credit Union (Credit Union) and agree that my accounts with the Credit
Union are and shall be governed by the terms and conditions of the
Membership and Account Agreement, Truth-in-Savings Rate and Fee Schedule,
Funds Availability Policy Disclosure, Overdraft Protection Agreement
(if applicable), and if an Access Card or EFT Service is requested,
I/we agree to the terms of and acknowledge receipt of the Electronic
Funds Transfer Agreement. In addition I agree to be bound by all of
the Credit Union's by-laws and amendments thereto which may be adopted
from time to time by the Credit Union. I hereby authorize the Credit
Union to obtain credit reports and investigations as it may deem necessary
to establish my accounts and loans. I/we acknowledge receipt of a
copy of the Agreements and Disclosures applicable to the accounts
and services requested herein.
Under penalties of perjury, I certify
that: (1) The number shown on this form is the correct security number/taxpayer
identification number (or I am waiting on the receipt of a number)
and (2) I am not subject to backup withholding (unless indicated below)
because: (a) I am exempt from backup withholding, or (b) I have not
been notified by the IRS that I am subject to backup withholding as
a failure to report all interest or dividends or (c) the IRS has notified
me that I am no longer subject to backup withholding.
The Internal Revenue Service
does not require your consent to any provision of this document other
that the certifications required to avoid backup withholding.
| |
I am subject
to backup withholding |
| |
I am not
a United States citizen or resident (complete W-8 Form) |
|
| Member's
Signature ____________________________________ |
Date
________________________ |
Joint
Owner's Signature _________________________________
|
Date________________________
|
| "I
__________________________________declare and affirm under oath that
I am a member of Shia Imami Ismaili Nizari community and residing in United States of America." |
|
You
Must Print, Sign, and Return to Credit Union
|
