Membership Application

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Member/Joint Owner Information
* Required Fields

* Primary Member Last Name	* First Name	MI
* Date of Birth
* Social Security #

Joint Owner Last Name	First Name	MI
Date of Birth
Social Security #
Relationship to Member

Joint Owner Last Name	First Name	MI
Date of Birth
Social Security #
Relationship to Member

Home Phone
* Cell Phone
* E-Mail Address

Physical Address

* Street Address
* City * State * Zip

Mailing Address (if different from above)

Address/PO Box
City State Zip

Eligible by Employment

* Employer Name
Employer Address
City State Zip
Employer/Work Phone
Employment Hire Date

Eligible by Family Member

Family Member's Name
Relation to Family Member
Family Member's Phone No.

UFCW Local 1776 Federal Credit Union Membership Agreement
I/We hereby make application for membership in the UFCW Local 1776 FCU and agree to conform to its bylaws and amendments thereof, and to subscribe for at least one (1) share. I/We authorize the Credit Union to obtain and use consumer reports (including credit) to process this application. I/We hereby acknowledge receipt of a copy of the disclosures attached hereto for the account(s) opened hereon and agree to be bound by the same. Under penalties of perjury, I/We certify that (1) the Social Security Number(s) on this form are our correct taxpayer identification number(s) and (2) I/We are not subject to backup withholding because (A) I/We are exempt from backup withholding, or (B) I/We have not been notified by the Internal Revenue Service (IRS) that I/We are subject to backup withholding as a result of a failure to report all interest or dividends, or (C) the IRS has notified me/us that I/We am no longer subject to backup withholding. Member Account Agreement (opens in a new tab/window) By submitting this Membership Application, I/We acknowledge reading and agree to the terms of the Member Account Agreement.

UFCW Local 1776 Federal Credit Union Membership Agreement

I/We hereby make application for membership in the UFCW Local 1776 FCU and agree to conform to its bylaws and amendments thereof, and to subscribe for at least one (1) share. I/We authorize the Credit Union to obtain and use consumer reports (including credit) to process this application. I/We hereby acknowledge receipt of a copy of the disclosures attached hereto for the account(s) opened hereon and agree to be bound by the same.

Under penalties of perjury, I/We certify that (1) the Social Security Number(s) on this form are our correct taxpayer identification number(s) and (2) I/We are not subject to backup withholding because (A) I/We are exempt from backup withholding, or (B) I/We have not been notified by the Internal Revenue Service (IRS) that I/We are subject to backup withholding as a result of a failure to report all interest or dividends, or (C) the IRS has notified me/us that I/We am no longer subject to backup withholding.

Member Account Agreement

By submitting this Membership Application, I/We acknowledge reading and agree to the terms of the Member Account Agreement.