Membership Application * Required Fields Designate the Ownership/Responsibility for the Account: Individual Joint Account with Survivorship Primary Account Owner Information First Name: Middle Initial: Last Name: Social Security Number/TIN: Social Security Number/TIN: Social Security Numer Field 1 - Social Security Number/TIN: Social Security Numer Field 2 - Social Security Number/TIN: Social Security Numer Field 3 Date of Birth: Date of Birth: Month Month... January February March April May June July August September October November December / Date of Birth: Day Day... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Date of Birth: Year Year... 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 Membership Eligibility: CLEET Peace Officer: Select... Yes No Primary Owner: Home Address Information Address: Address 2: City: State: Select... AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY ZIP: Phone Numbers and E-mail Address Home Phone Number: Cell Phone Number: Work Phone Number: Owner Email Address: Employment Information Employer: Occupation / Job Title: County: Employed Since: Employed Since: Month Month... January February March April May June July August September October November December / Employed Since: Day Day... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Employed Since: Year Year... 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 First Joint Account Owner Information First Name: Middle Initial: Last Name: Social Security Number / TIN: Social Security Number / TIN: Social Security Numer Field 1 - Social Security Number / TIN: Social Security Numer Field 2 - Social Security Number / TIN: Social Security Numer Field 3 Date of Birth: Date of Birth: Month Month... January February March April May June July August September October November December / Date of Birth: Day Day... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Date of Birth: Year Year... 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 Relationship to Primary Account Owner: Phone Numbers and E-Mail Address Home Phone Number: Cell Phone Number: Work Phone Number: Email Address: Employment Information Employer: Occupation / Job Title: Payable on Death (POD) Beneficiary / Payee 1st Beneficiary / POD Payee: Address: Address 2: City: State: Select... AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY ZIP: 2nd Beneficiary / POD Payee: Address: Address 2: City: State: Select... AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY ZIP: Optional Account Services Set up Payroll Deduction? Yes No Employer's Name: Deduction Action: I have this day authorized the payroll department to deduct the following amount from my pay each period until further notice from me.: I have read and agree to the terms of use Access your funds through the use of ATM and/or Point of Sale (POS)* purchases wherever VISA is accepted. *POS transactions require an open & funded Electronic Checking Account A Debit Card will be automatically issued to the Primary Owner. Second Debit Card: YES, please issue a Debit Card to the Joint Owner NO, please do not issue a Debit Card to the Joint Owner SSN / TIN Certification and Backup Withholding Information (A) By signing below, I certify under penalties of perjury that (1) the Taxpayer Identification Number (TIN) shown on this Membership Application Form is my correct TIN and I am not subject to backup withholding either because (a) I have not been notified by the Internal Revenue Service that I am subject to backup withholding as a result of a failure to report all interest or dividends or (b) the IRS has notified me that I am no longer subject to backup withholding.(B) I am not a U.S. Person or U.S. Resident Alien. (Complete/submit a separate form W-8 Ben) Agreement and Authorization By signing below, I/we agree to Fraternal Order of Police Federal Credit Union's by-laws and the terms and conditions of the Membership and Account Agreement, Truth-In-Savings Disclosure, Funds Availability Policy Disclosure, if applicable, and to any amendment the Credit Union makes from time to time which are incorporated herein. I/We acknowledge receipt of a copy of the Agreement and Disclosures applicable to the accounts and services requested herein. If an access card or Electronic Funds Transfer (EFT) service is required and provided, I/we agree to the terms of and acknowledge receipt of the Electronic Funds Transfer Agreement.I/We hereby authorize Fraternal Order of Police Federal Credit Union to verify credit and employment history by any necessary means, including access of a consumer credit report from any consumer reporting agency for any information it deems necessary for approval of this application as well as any credit products requested now or in the future. This signature applies to all accounts under my/our name(s) at Fraternal Order of Police Federal Credit Union. In compliance with the USA Patriot Act, I understand Fraternal Order of Police Federal Credit Union is required to obtain and verify identification provided for all new account owners and joint owners, using methods permitted by law.Joint Owner Agreement: Fraternal Order of Police Federal Credit Union is hereby authorized to recognize any of the signatures subscribed hereof in the payment of funds or the transaction of any business for this account. 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 from the Credit Union.Upon issue of a Personal Identification Number (PIN), this number should be memorized. DO NOT write it on your card or keep in your wallet/purse. After memorizing it, you should destroy it. Your accounts can be accessed by the use of the card with the PIN. If you forget your PIN, contact the Credit Union and we will issue you a new one. By the signing of this application, I acknowledge that I understand the use of my PIN/Password has the same legal effect as my written signature. I further understand that I am responsible for all transactions made through internet homebanking/bill-pay and if I disclose my PIN/Password to anyone, I am aware they have access to all of my accounts and that I am responsible for his/her transactions.The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid backup withholding. Type your name as your signature to this application: Security Code: Security Code Go to main navigation
