Membership Account Application printable pdf download

Membership Account Application

Member Information

Last Name

First Name

Middle Initial

Street Address

City

State

Zip

Date of Birth

Mother’s Maiden Name (Security Code)

Email Address

Driver’s License Number / State

Home Phone Number

Business Phone Number

Eligibility For Membership

Currently Employed By

Division/Dept

Family Member or Sponsor Name

Sponsors Phone Number

Taxpayer’s Identification Number Or Social Security Number

New Member Number

Part I. Enter your (Payee) Taxpayer Identification Number (TIN) or Social Security Number

Part II. Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a

number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been

notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all dividends, or (c) the IRS has

notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person. I understand that if I am not a U.S. citizen

or other U.S. person, I must submit the appropriate IRS Form W-8 with the membership application.

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid back up with holding.

This account shall be:

Individual

Joint

With Payable-On-Death (POD) Provision

Joint Owner Information

Last Name

First Name

Middile Initial

Date of Birth

Street Address (if different from address listed above)

City

State

Zip

Social Security Number

Driver’s License Number / State

Mother’s Maiden Name (Security Code)

Email Address

Home Phone Number

Business Phone Number

Account Authorization Type

Separate application required for the following

Share/Savings Account*

Classic Money Market Account*

Share Certificate

Premier Account

IRA

Revocable/Irrevocable Trust

Checking Account

Club Savings Account*

Alumni Account

Automatic Overdraft Protection

I authorize you to automatically pay any overdraft(s) on my checking account(s) from my account(s) listed below:

Share/Savings*

Premier Savings*

Checking Line of Credit

(requires separate application)

No more than six (6) pre-authorized automatic or telephone transfers allowed from any savings per month. See Rate and Fee Schedule for details.

Debit Authorization

I authorize Coca-Cola Federal Credit Union to initiate a charge (debit) entry at the Financial Institution indicated below, and initiate adjustments (if necessary) for any transactions debited in error. I

acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.

I ______________________________________________________________________________________________,authorize

Financial Institution Name

9 Digit Routing Number

Account Number

Amount (One-time only, $1,000.00 limit)

Membership Account Application • Page 1 of 2

Form # 03-06-515