Secure Membership Form

Membership Eligibility:

Personal Information

First Name

Middle Initial

Last Name

Street Address

City

State

Zip Code

Date of Birth (mm/dd/yyyy)

Phone #:

Email Address:

Social Security #:

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*

Interested in:

Savings

Checking

Certificates

Visa Debit Card

Certification as to Taxpayer Identification Number & Backup Withholding
Under penalties of perjury, I certify (1 ) that the number shown on this form is my correct taxpayer identification number (S.S. #) and (2) that I am not subject to backup withholding either because I have not been notified that I'm subject to backup withholding as a result of or failure to report all interest or dividends, or the Internal Revenue Services (IRS) has notified me that I am no longer subject to backup
withholding.
Fees include $25.00 for initial deposit and $5.00 for the application fee; total of $30.00.