Mother's Maiden Name:
You need not furnish Alimony, Child Support or Maintenance Income information if you do not want us to consider it in evaluating your application
Name and address of nearest relative not living with you:
Name of Relative:
Street Address of Relative:
Joint Applicant Information:
Check to apply jointly
Check additional services you desire:
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 submitting this form, 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 submitting this form, 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
Note: All disclosures also may be viewed on our web site at www.countryside.org
TIN certification and backup withholding information
By submitting this form, 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
I am NOT a United States citizen or resident (complete appropriate W-8 forms) The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
Thank you for your application to Countryside Federal Credit Union. You will be notified of approval/denial within 24-hours of the Credit Union's receiving this form. Please understand that the Credit Union may require additional paperwork and/or information to process this request.