First Name Last Name Middle Initial Type of ID: ID number: SSN #: Complete Address: Address City State -- AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Home phone: Work phone: Email: Husband's First or Wife's Maiden Name: Employer: Dept / Occupation: Place of Birth: Date of Birth: Mother's Maiden Name: MEMBERSHIP ELIGIBILITY Employer Group Family Member or Living in Household Employer Group Name -- Cambridge University Press City of Mt. Vernon City of New Rochelle City of Yonkers County of Westchester E&G Employees FCU Faculty Student Association of Westchester Community College Fairview Fire Department Greenburgh Municipal Housing Authority Hudson Valley Developmental Disabilities Services Office Mt. Vernon Board of Education Mt. Vernon Civil Service Mt. Vernon Neighborhood Health Center New Rochelle Board of Education New Rochelle Municipal Housing Authority New Rochelle Public Library New York State Police NYS Department of Health Pelham Board of Education Portchester Nursing Home SUNY-Purchase Campus Town of Eastchester Town of Greenburgh Town of Mt. Pleasant Town of North Castle Town of North Salem Town of Warwick (PBA) Town of Yorktown Village of Goshen Village of Harrison Village of Mamaroneck Village of Ossining Village of Pelham Manor Village of Portchester Village of Scarsdale Village of Tuckahoe Westchester Medical Center White Plains Administration Judges Office White Plains Board of Education White Plains Police Dept Yonkers Municipal Housing Authority Member Name OPTIONAL PAYROLL DEDUCTION To establish automatic deposits into your new account, through payroll deduction, simply provide the applicable information below. Please allow 2-3 pay periods for the deposits to begin. You may stop or change the amount anytime you choose. Savings $ Holiday Club $ Vacation Club Other $ Description (please describe other, i.e. checking, child's account) Other $ Description (please describe other, i.e. checking, child's account) Total Deduction $ ACCOUNT DESIGNATION Payable on Death (POD) Trust Account All Accounts Designate Specific Accounts Relation to Member Beneficiary Street City/State/Zip Relation to Member Beneficiary Street City/State/Zip UTTMA/UGMA (as custodian for {minor} under the uniform Transfers/Gifts to minors act) Minor’s TIN/SSN (Instruction to Signer: If you have been notified by the Internal Revenue Service (IRS) that you are subject to backup withholding due to payee under reporting and you have not received a notice from the IRS that the backup withholding has terminated, you must strike out the language in clause 2 of the certification you sign below.) CERTIFICATION AS TO TAXPAYER IDENTIFICATION NUMBER AND BACKUP WITHHOLDING Under penalties of perjury, I certify (1) that the number shown on this form is my correct taxpayer identification number (2) that I am not subject to backup with-holding either because I have not been notified that I am subject to backup with-holding as a result of a failure to report all interest or dividends, or the Internal Revenue Service (IRS) has notified me that I am no longer subject to backup withholding and (3) that I am a U.S. person (including a U.S. resident alien). By signing below, I hereby make application for membership in agreement to conform to the bylaws and any amendments thereof in the Educational & Governmental Employees Federal Credit Union. I also agree to the terms and conditions of any account that I have in the credit union now or in the future and agree that the credit union may change those terms and conditions from time to time. JOINT SHARE ACCOUNT AGREEMENT "NOT TRANSFERABLE" The Educational & Governmental Employees Federal Credit Union is hereby authorized to recognize any of the signatures subscribed below 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 herefore or hereafter paid in on shares by any or all of joint owners to their credit union as such joint owners with all accumulations thereon, are and shall be owned by them jointly, with right of survivorship and be subject to the withdrawal or receipt of any of them, and payment to any of them or the survivor or survivors shall be valid and discharge said credit union from any liability for such payment. The joint owners also agree to the terms and conditions of the account as established by the credit union from time to time. Any or all said joint owners may pledge all or any part of the shares in this account as collateral security to a loan or loans from the credit union. The right or 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 therefore made. Soc. Sec or Tax ID No. Joint Owner Name Date of Birth Consent of Spouse (to be completed in some states if joint owner is other than spouse of member) *as defined in 12 CFR Part 204 Comments Comments: By selecting the "I Agree" and submitting, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "I Agree" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third-party verification is necessary to validate your E-Signature, and that the lack of such certification or third-party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and the Credit Union. By selecting "I Agree", I consent to abide by the terms and policies as set forth by the credit union. Please refer to the disclosure links below for details. I agree Disclosures Electronic Communication Consent and Notice Privacy Notice Truth-In-Savings Disclosure Electronic Fund Transfers Your Ability To Withdraw Funds Terms and Conditions of your Account Common Features Signature (Enter Name) Co-Applicant Signature (Enter Name)
