Certificate Request Form Page 2
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Print
Suffix
___________
FOR OFFICE USE ONLY
Date
Checking/IMMA digit
CERTIFICATE REQUEST
Employee
Office
N$
O$
Please print:
(1) Savings Account No. _____________________________________
(2) ID No. _____________
(3) Term
Choose one...
Rate _______________ % per annum.
(4) Make the initial deposit from:
Check or Money Order
Bank Wire
Transfer from my CEFCU:
Savings
Insured Money Market (IMMA) (suffix __________)
Checking (suffix __________)
Certificate (suffix __________)
(penalty may apply)
(5) Acct. No. ____________________ the amount of $_________________
□
Number of Certificates requested:
$_____________
$_____________
$_____________
$_____________
$_____________
$_____________
$_____________
$_____________
$_____________
$_____________
(6) Member Information:
Name ________________________________________________________________________
________________________________
(first, middle initial, last)
Social Security Number
Address _________________________________________________________________________________________________________
City ______________________________________________________________ State____________________ Zip_________________
Daytime Phone No. _______________________
(7) Joint Member Information:
__________________
_______________________________
Name
________________________________________________________
(first, middle initial, last)
Date of Birth
Social Security Number
________________________________________________________
_________________
________________________________
Name
(first, middle initial, last)
Date of Birth
Social Security Number
________________________________________________________
__________________ ________________________________
Name
(first, middle initial, last)
Date of Birth
Social Security Number
(8) Please post my (our) dividends:
Savings
Checking (suffix__________)
IMMA (suffix__________)
Certificate
Monthly to:
(9) Account to receive dividends:
Acct. No. __________________________ ID No. _____________
Name
_______________________________________________________________________________
(11) I (We) agree to the terms and provisions hereof and of the Truth-In-Savings Rate Schedule (Rate Schedule) and the Deposit Account
Agreement (Agreement) and acknowledge receipt of a copy of the Rate Schedule and Agreement. All primary and joint member signatures
required.
_________________________________________________
______________________________________________
(Primary Member Signature)
(Joint Member Signature)
_________________________________________________
______________________________________________
(Joint Member Signature)
(Joint Member Signature)
____________________________________________________________________________________________________________________
FOR OFFICE USE ONLY
SFX
__________
__________
__________
__________
__________
__________
__________
__________
__________
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Parent category: Business