Join Countryside Federal Credit Union

Simplified Member Sign-up (Complete & return with a minimum deposit of $5.00 to open a savings account)

Membership is open to persons who live, work, worship, or attend school in, and businesses and other legal entities located in Onondaga County, New York. -- Please make sure you have the following items completed prior to opening your account: 1-Completed Application 2-A valid driver's license, passport or non-drivers license (if you are mailing, please send a photocopy) and 3-$5.00 initial deposit.

Personal Information:

*Member Name:

*SS#:

*Date of Birth:

*Street Address:

*City:

*State:

*Zip Code:

*Home Phone:

Work Phone:

Alt. Phone:

E-mail:

*Driver's License #:

*State:

*Mother's Maiden Name:

Employment Information:

*Company Name:

*Gross Annual Salary:

*Years with Employer:

Other Income:

Source:

(You need not furnish Alimony, Child Support or Maintenance Income information if you do not want us to consider it in evaluating your application)

Residence Information:

*Currently do you: Own Rent

Monthly Payment:

Other Assets:

Your Vehicle

Make:

Model:

Year:

Name & Address of Nearest Relative Not Living With You:

*Name of Relative:

*Street Address of Relative:

*City:

*State:

*Zip Code:

Joint Applicant Information:

*Joint Member's Name:

SS#:

Date of Birth:

Street Address of Joint Member:

City:

State:

Zip Code:

Driver's License #

State:

Employer:

Check any Additional Services You Desire at this Time:

Direct Deposit:
VISA® ATM / Plastic Check Card:
Checking (Share Draft) Account:

(Line-of-Credit available to qualified members for Overdraft Protection)

Internet Teller Access / Bill Paying:
Money Market Account:
Credit Cards:

For more information, disclosures, or to apply for a Countryside FCU credit card, call 800-551-0839

Holiday Club:
Vacation Club:
"U Name It" Club:
Share Certificate(s):

(minimum $500 deposit)

Amount:

Roth IRA:
Education IRA:
Traditional IRA:

Other Type of Loan Desired:

Other Loan Amount:

Line-of-Credit Desired Limit:

Determine my Limit:

I hereby make application for membership in the Countryside Federal Credit Union and agree to conform to its laws and amendments thereof and subscribe for at least one share. NON-TRANSFERABLE. This application approved by the Board of Directors and entered.

The Countryside Federal Credit Union is hereby authorized to recognize any of the signatures subscribed hereto in the payment of funds or the transaction of any business for this account. The joint owners of this account, hereby agree with each other and with said Credit Union that all sums now paid in on shares, or heretofore or hereafter paid in on shares by any or all of said joint owners to their credit as such joint owners with all accumulations thereon, are and shall be owned by them jointly with right of survivorship and be subject to withdrawal or receipt of any of them, and payment to any of them or the survivors shall be valid and discharge said Credit Union from any liability for such payment.

Any or all of said joint owners may pledge all or any part of the shares in this account as collateral security to a loan or loans.

The right of authority of the credit union under this agreement shall not be changed or terminated by said owners, or any of them except by written notice to said credit union which shall not affect transactions theretofore made.

By signing below, you certify that the information on this Account Card is complete, true, and submitted for the purpose of obtaining the accounts and services requested. You agree:(a)that the Credit Union can use credit reporting agencies or otherwise verify the information on this Account Card for the purpose of extending credit or services to you or reviewing or collecting a credit account of yours:(b)that the Credit Union can tell others about its credit experience with you and obtain information from others about your credit history and performance. If you request, the credit union will tell you the name and address of any credit reporting agency from which it received a credit report on you.

By signing below, you acknowledge receipt of, and agree to the terms of the following Agreements:

Membership and Account Agreement
Overdraft Loan Agreement
Electronic Funds Transfer Agreement
Internet Teller/Bill Paying (optional)

Note: All disclosures also may be viewed on our web site at www.countryside.org

TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION

By signing below, I certify under penalties of perjury, that:(1)I am a U.S. person (including a U.S. resident alien); (2)the Social Security number (SSN)/taxpayer identification number (TIN)shown is my/the correct identification number; and (3)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 all dividends or interest, or because the IRS has notified me that I am no longer subject to

I am subject to withholding
Exempt
I am not a United States Citizen or resident (complete appropriate W-8 form) The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

I will be notified of approval/denial within 24-hours of the Credit Union's receiving this form. I understand that the Credit Union may require additional paperwork and/or information to process this request.

Signature - Owner

Date

Signature - Joint Owner

Date

Print Form

Office Use Only:

Member Number:

Member Group #:

Eligibility / x-ref:

Date:

Initials

Visa
Checking
Loan
Add Joint Owner
IRA
Add Services