Effective October 1, 2003 In accordance with section 326 of the USA Patriot Act, Chadron Federal CU is required by Federal law to obtain, verify, and record information that identifies each person who opens an account or is being added as a signatory to a new or existing account. In some cases, identification will be requested for those banking with us prior to the effective date of the customer identification requirements because original documentation was not obtained with the opening of the accounts. What this means for you: When you open an account or are going to be added as a signatory to an account, we will ask for you 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. |
General Information |
Please provide all the requested information. When you have completed the form, press the Submit button to send your application. If necessary, we will contact you for additional information. If you wish to apply for a loan as well, please note this in the Special Instructions/Comments field at the end of the application and the Credit Union will contact you. There is no need for you to fill out a seperate loan application as long as you include this information. |
| * Required Field |
| Will there be a co-applicant on this application? |
|
| Membership Eligibility |
|
Primary Applicant |
| * Last Name | |
| * First Name | |
| Middle Name | |
| * Social Security Number | - - |
| * Date of Birth | / / (mm/dd/yyyy) |
| * Home Phone Number | () - |
| Work Phone Number | () - ext |
| Cell or Other Phone | () - ext |
| Email Address | |
| Backup Withholding Tax |
|
| Citizenship |
|
| Driver's License # | |
| Driver's License State | |
| Mother's Maiden Name | |
Home Address |
| * Street Address | |
| Apt. | |
| * City | |
| * State | |
| * Zip | |
| Current Time at Residence | |
| Residence Type |
|
Mailing Address (if different) |
| Street Address | |
| Apt. | |
| City | |
| State | |
| Zip | |
Present Employer |
| Name | |
| Phone Number | () - ext |
| Job Title | |
| Job Start Date | / / (mm/dd/yyyy) |
| Street Address | |
| Suite | |
| City | |
| State | |
| Zip | |
Co-Applicant (if applicable) |
| Last Name | |
| First Name | |
| Middle Name | |
| Relationship to Primary Owner | |
| Social Security Number | - - |
| Date of Birth | / / (mm/dd/yyyy) |
| Home Phone Number | () - |
| Work Phone Number | () - ext |
| Cell or Other Phone | () - ext |
| Email Address | |
| Driver's License # | |
| Driver's License State | |
| Mother's Maiden Name | |
Home Address |
| Street Address | |
| Apt. | |
| City | |
| State | |
| Zip | |
| Current Time at Residence | |
| Residence Type |
|
Mailing Address (if different) |
| Street Address | |
| Apt. | |
| City | |
| State | |
| Zip | |
Present Employer |
| Name | |
| Phone Number | () - ext |
| Job Title | |
| Job Start Date | / / (mm/dd/yyyy) |
| Street Address | |
| Stuie | () - ext |
| City | |
| State | |
| Zip | / / (mm/dd/yyyy) |
Co-Applicant 2 (if applicable) |
| Last Name | |
| First Name | |
| Middle Name | |
| Relationship to Primary Owner | |
| Social Security Number | - - |
| Date of Birth | / / (mm/dd/yyyy) |
| Home Phone Number | () - |
| Work Phone Number | () - ext |
| Cell or Other Phone | () - ext |
| Email Address | |
| Driver's License # | |
| Driver's License State | |
| Mother's Maiden Name | |
Home Address |
| Street Address | |
| Apt. | |
| City | |
| State | |
| Zip | |
| Current Time at Residence | |
| Residence Type |
|
Mailing Address (if different) |
| Street Address | |
| Apt. | |
| City | |
| State | |
| Zip | |
Present Employer |
| Name | |
| Phone Number | () - ext |
| Job Title | |
| Job Start Date | / / (mm/dd/yyyy) |
| Street Address | |
| Stuie | () - ext |
| City | |
| State | |
| Zip | / / (mm/dd/yyyy) |
Nearest Relative Not Living With You |
| Last Name | |
| First Name | |
| Relationship | |
| Phone Number | () - ext |
| Street Address | |
| Apt. | |
| City | |
| State | |
| Zip | |
Additional Information |
| Special Instructions / Comments | |
| How would you like to be contacted? |
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The Internal Revenue Service does not require your consent to any provision of this contract other than the certifications required to avoid backup withholding. If you wish to apply for a loan as well, please note this in the Special Instructions/Comments field and the Credit Union will contact you. There is no need for you to fill out a seperate loan application as long as you include this information. |
| Security Code What's this? | |
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