St. Thomas Employee Hospital Credit Union - Membership Application Page

Please complete, print out, sign where indicated and mail form to the credit union.

ACCOUNT TYPE

Share/Savings IRA Share Draft/Checking Share Certificate/Certificate

Other

Other

TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION

By signing below, I certify in accordance with the IRS W-9 instructions provided by the Credit Union and under penalties of perjury, that the Social Security number (SSN)/Taxpayer identification number (TlN) 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 ad 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

		Account No.:
Member:
Street:		SSN/TIN:
City/State/Zip:		Driver’s Lic. No.:
Home Phone:		Date of Birth:
Work Phone:		Mother’s Maiden Name:
Employment:
Eligibility for Membership:

AUTHORIZATION

By signing below, We agree to the terms and conditions of the Membership and Account Agreement, Truth-in-Savings Rate and 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 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 provisions of this document other than the certifications required to avoid backup withholding.

X____________________________ __________
Applicant Signature Date

X____________________________ __________
Co-Applicant Signature Date

ACCOUNT SERVICES

Payroll Deduction/Direct Deposit ATM Card Debit Card

Overdraft Protection (Indicate transfer priority below)

Other EFT Service:

Other:

ACCOUNT OWNERSHIP

Designate the ownership of the accounts and responsibility for the services requested.

Single Party Multiple Party with Survivorship Multiple Party without Survivorship

Joint Owner

Street:		SSN/TIN:
City/State/Zip:		Driver’s Lic. No:
Phone Home:		Date of Birth:
Phone Work:		Mother’s Maiden Name:

Joint Owner

Street:		SSN/TIN:
City/State/Zip:		Driver’s Lic. No:
Phone Home:		Date of Birth:
Phone Work:		Mother’s Maiden Name:

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)