Fields marked with * are compulsory MEMBER APPLICATION AND OWNERSHIP INFORMATION First Name * Last Name * Street Address * City State ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Primary Phone * Primary Phone Type * SelectListedUnlisted Work Phone E-mail * SSN/TIN * Driver's Lic. Number Date of Birth * Password Employer * Membership Eligibility *Select CountyKentSussexNew CastleChesterDelawareAccomackNorthamptonCarolineCecilDorchesterQueen Anne’sSomersetTalbotWicomicoWorchester Select Employment *Select EmploymentFamily MemberState PoliceGovernmental Criminal Investigation OfficesDEASheriffs & Constables OfficesMarshall’s OfficeEmergency Dispatch DepartmentsTSAPolice Departmentsthe FBIFederal Police ServicesHighway PatrolPark PoliceCorrectional FacilitiesProbation & Parole Account Ownership IndividualJoint Account with Right of SurvivorshipJoint Account without Right of Survivorship Number of Joint Owner(s) Select Number of Joint Owner(s)123 JOINT OWNER 1 Joint Owner Name Street Address City State ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Primary Phone Primary Phone TypeSelectListedUnlisted Work Phone E-mail SSN/TIN Driver's Lic. Number Date of Birth Password JOINT OWNER 2 Joint Owner Name Street Address City State ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Primary Phone Primary Phone TypeSelectListedUnlisted Work Phone E-mail SSN/TIN Driver's Lic. Number Date of Birth Password JOINT OWNER 3 Joint Owner Name Street Address City State ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Primary Phone Primary Phone TypePrimary Phone TypeListedUnlisted Work Phone E-mail SSN/TIN Driver's Lic. Number Date of Birth Password ACCOUNT DESIGNATION - Payable on Death(POD)/ Trust Account Beneficiary/POD Payee Street Address City State ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip SSN Date of Birth ACCOUNT DESIGNATION - UTMA/UGMA Name of Minor Minor SSN/TIN Account Type I/We agree to the terms & conditions Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued), and (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and (3) I am a U.S. citizen or other U.S. person. For federal tax purposes, you are considered a U.S. person if you are: an individual who is a U.S. citizen or U.S. resident alien; a partnership, corporation, company, or association created or organized in the United States or under the laws of the United States; an estate (other than a foreign estate); or a domestic trust (as defined in Regulations section 301.7701-7). (4) The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification Instructions Cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. Complete a W-8 BEN if you are not a U.S. person. If a W-8 BEN is completed, your signature does not serve to certify this section. AUTHORIZATION By signing below, I/we agree to 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 agreements and disclosures applicable to the accounts and services requested herein. If an access card or EFT service is requested and provided, I/we agree to the terms of and acknowledge receipt of the Electronic Fund Transfers Agreement and Disclosure. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. Signature of Individual * Date
