CBS Employees FCU

Membership Application

Minimum Opening Deposit $26.00
($25.00 Minimum Balance = $1.00 Membership Fee)

Applicant

Name
( Last - First - Initial)

Mother's Maiden Name

Address

City

State

Zip

Driver's License #

Home Phone #

Employer

work Phone #

Date of Birth

Pager #

Social Security #

E-mail

Under penalties of perjury I certify that (1) the above number is my correct taxpayer identification number AND (2) I am not subject to backup withholdings from the IRS because (a) I have not been notified tha tI am subject to backup withholding as a result of a failure to report all dividends or interest, or (b) the IRS has notified me I am no longer subject ot back withholdings. I must cross out above item (2) if I have been notified by the IRS that I am currently subject to backup withholdings.

_______________________________________________________________________________________
Signature	Date

Qualification

I am qualified for membership into the CBS Employees Federal Credit Union (CBS EFCU) because: (subject to certification)

I am an employee of

I am a relative of a member of the CBS EFCU:		Name of relative
Relationship		Phone #

Beneficiary (IES)

In the event of my death, or the death of myself and all other joint owners. I/We hereby designate as My/Our beneficiary (ies) to receive all shares in My/Our account to the follwing.

Name
Birth Date		Phone #

Name
Birth Date		Phone #

Joint Applicant Information

Name ( Last - First - Initial)		Date of Birth
Social Security #		Driver's License #
Home Phone #		Work Phone #
Mother's Maiden Name		E-mail

2ND Joint Applicant Information

Name ( Last - First - Initial)		Date of Birth
Social Security #		Driver's License #
Home Phone #		Work Phone #
Mother's Maiden Name		E-mail

Signatures

By signing below I/We agree to the terms stated on this form. I/We agree to be bound by the bylaws, regulations, policies & rules, and any amendments thereof, of the CBS Employees Federal Credit Union. You acknowledge receipt of the Truth-in-Savings agreement and to be bound by those terms.

_______________________________________________________________________________________
Member Signature	Date

_______________________________________________________________________________________
Joint Owner Signature	Date

_______________________________________________________________________________________
2ND Joint Owner Signature	Date

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