Membership Application

Membership Application

PO Box 20105

Cheyenne WY 82003

(800) 310-2197

Print this Application and Bring to one of our locations to

open your membership and receive a $25.00 Visa Gift card*

as a reward for your membership.

*Requires a new Checking account or a loan of $10,000 or more.

Primary Member

Membership Eligibility:

Joint Member

Family Member

Relationship

Family Member

Relationship

Under Served Communities

Zip Code

Under Served Communities

Zip Code

Employer Group

Group ID (Internal)

Employer Group

Group ID (Internal)

Primary Member

Member INFORMATION

Joint Member

Borrower’s Name (Last, First, Middle, include Sr./Jr. if applicable)

Co-Borrower’s Name (Last, First, Middle, include Sr./Jr. if applicable)

Address (Street, City, State, Zip)

Own

Rent

No. of Years

Address (Street, City, State, Zip)

Own

Rent

No. of Years

_______

_______

Home Telephone Number

Housing Pymt

Social Security Number

Date of Birth

Home Telephone Number

Housing Pymt

Social Security Number

Date of Birth

ID No./State

Complete for joint, secured credit or if you live in a

No. of Depen-

ID No./State

Complete for joint, secured credit or if you live in a

No. of Depen-

community property state

dants

community property state

dants

MARRIED

UNMARRIED

SEPARATED

(Excluding self)

MARRIED

UNMARRIED

SEPA-

(Excluding self)

RATED

Primary Member

EMPLOYMENT INFORMATION

Joint Member

Employer

Employer

Address (Street, City, State, Zip)

Address (Street, City, State, Zip)

Position or Job Title

Supervisor

Position or Job Title

Supervisor

Telephone Number

Hire Date

Monthly Salary

Telephone Number

Hire Date

Monthly Salary

Primary Member

OTHER INCOME

Joint Member

You need not list income from alimony, child support or separate maintenance unless you wish it considered for

purposes of granting this credit.

Type of Other Income

Monthly Amount

Type of Other Income

Monthly Amount

Primary Member

REFERENCES

Joint Member

Name of Nearest Relative (Not Living With You)

Relationship

Name of Nearest Relative (Not Living With You)

Relationship

Address of Relative (Street, City, State, Zip)

Telephone Number

Address of Relative (Street, City, State, Zip)

Telephone Number

I hereby agree to grant the credit union a security interest in all present and future shares and deposits with the credit union except Individual Retirement Account(s)

and other accounts which provide tax benefits under federal or state law to secure this VISA® account. Upon default, I agree that the credit union may apply any or

all of my shares and deposits to pay amounts due, or to pay the entire balance due on the account. I also agree to grant the credit union a security interest in collateral

(other than real estate or my residence) securing other loans with the Credit Union to secure credit.

_____________________________________________________________

____________________________________________________________

Primary Member Signature

Joint Member Signature

By signing below, I certify that the information contained within this application and on any attachments, either written or printed is true and correct and represents my current financial condition

accurately, and that I have no other debts than those stated. If there are important changes, I will notify you in writing immediately. I understand that any false statements or willful over -evaluation

of land, property or security for the purpose of influencing in any way the action of any federally insured credit union upon any loan application is a violation of Section 1014, Title 18, U.S. Code.

I authorize you to gather whatever credit and employment information you consider necessary and appropriate. I authorize you to give information concerning your credit experience with me to

others. I understand that you will retain this application whether or not credit is approved. If this application is signed by more than one person, the words “I” and “my” shall mean all those who sign

the application.

I acknowledge receipt of, and agree to, the terms of the Visa Agreement.

I acknowledge having received and read the Interest Rate, Interest Charges, and Fees Addendum attached to this application.

YOU MAY BE ASKED TO SUBMIT A COPY OF A CURRENT PAYCHECK STUB OR OTHER DOCUMENTATION AS NEEDED.

X_______________________________________________________________

X_________________________________________________________

______

Borrower’s Signature

Co-borrower’s Signature

OFFICE USE ONLY

DATE

Approved by

Member Number