Secure Membership Application

Membership Application

Field of Membership

First Name

Middle Initial

Last Name

Date of Birth

Email Address

Phone Type

Phone Number

Driver's License #

DL State of Issue

DL Issue date

DL Expiration date

SSN

This is a secure application but if you are uncomfortable providing your SSN here you may call us with this info after submission. We cannot process your application without this information.

Mother's Maiden Name

Present Address

Street Address

City

State

Zip Code

Months at present address

Present Employer

Employer

Job Title

# of Months Employed

Employer Address

Is there a joint applicant?

No Yes

Joint Applicant Information

First Name

Middle Initial

Last Name

Date of Birth

Email Address

Phone Type

Phone Number

SSN

This is a secure application but if you are uncomfortable providing your SSN here you may call us with this info after submission. We cannot process your application without this information.

Driver's License #

DL State of Issue

DL Issue date

DL Expiration date

Mother's Maiden Name

Joint Applicant Present Address

Street Address

City

State

Zip Code

Months at present address

Joint Applicant Present Employer

Employer

Job Title

# of Months Employed

Employer Address

Beneficiaries

Full Name

Home Address

Relationship

Phone #

Full Name

Home Address

Relationship

Phone #

Full Name

Home Address

Relationship

Phone #

Joint Share Account Agreement *Not Transferable

BHCU 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 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 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. 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 theretofore made.

How did you learn about BHCU?

Interested In

You agree to receive communications and disclosures electronically.

To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account we will ask for your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. All applications are subject to eligibility and Credit Union approval.

Taxpayer Certification

Under penalty of perjury, I certify (1) that the number shown on this card is my correct taxpayer identification number and (2) that I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding. The IRS does not require the taxpayer to agree to the contractual provisions included on this form and (3) I am a U.S. person (including a U.S. Resident Alien).

I hereby make application for membership in and agree to conform to the Bylaws, as amended, of BHCU (the ‘‘Credit Union’’). I certify that: I am within the field of membership of this Credit Union; the information provided on this application is true and correct; and my signature on this card applies to all accounts under my name at this Credit Union. (I have received disclosure for any Credit Union accounts I now have and agree to the terms and conditions set forth for those and any future accounts. I also agree the Credit Union may change these terms and conditions from time to time. This account may not be pledged, transferred, or assigned to any party other than the Credit Union.) Credit Union has the ability to close account if you did not qualify for membership at the time of account opening. I also agree to be bound to the terms and conditions of any account that I have in the Credit Union now or in the future.

The credit union prohibits the use of birth dates, social security or driver’s license numbers for usernames, passwords, and personal identifier numbers.

I have read this section and agree to the terms.