Membership Application 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. Section 1: General Information * Required Fields Section 1 What account types do you want to open? Savings Checking Money Market Youth Are you a current member of Great Falls FCU? No Yes Membership Eligibility: I live in Androscoggin County, Monmouth or Litchfield. I work in Androscoggin County, Monmouth or Litchfield. I attend school in Androscoggin County, Monmouth or Litchfield. I have an immediate family member who is an existing member of the credit union. Will there be a joint account holder on this application? No Yes Section 2: Primary Applicant First Name: Last Name: Middle Name: Mother's Maiden Name: Social Security Number: Social Security Number: Social Security Numer Field 1 - Social Security Number: Social Security Numer Field 2 - Social Security Number: 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 Primary Phone Number: Secondary Phone Number: Email Address: Backup Withholding Tax: I am NOT subject to backup withholding tax I am subject to backup withholding tax Are you a U.S Citizen? Yes No Please Upload a Photo of your Driver's License: If your current address does not match the address on your license, we will need additional proof of address. Additional documents we can accept showing proof of your current address are: • Rental Lease • Utility Bill (Residential) • Signed Notice from Landlord • Property Tax Bill • Mortgage Deed • Mortgage Statement • Voter Registration Card: Home Address Street Address: Street 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: If Other, please explain: Mailing Address (if different) Street Address: Street 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: Current Employer Name: Occupation: Section 3: Joint-Applicant (if not applicable, skip to Section 4) Joint First Name: Joint Last Name: Joint Middle Name: Relationship to Primary Owner: Joint Social Security Number: Joint Social Security Number: Social Security Numer Field 1 - Joint Social Security Number: Social Security Numer Field 2 - Joint Social Security Number: 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 Joint Primary Phone Number: Joint Secondary Phone Number: Joint Email Address: Please Upload a Photo of the Joint Applicants Driver's License: If your current address does not match the address on your license, we will need additional proof of address. Additional documents we can accept showing proof of your current address are: • Rental Lease • Utility Bill (Residential) • Signed Notice from Landlord • Property Tax Bill • Mortgage Deed • Mortgage Statement • Voter Registration Card: Joint Mother's Maiden Name: Joint Applicant's Home Address Street Address: Street 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: Mailing Address (if different) Street Address: Street 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: Joint Applicant's Current Employer Company Name: Job Title: Section 4: Initial $25 Deposit and ACH Information We require a $25 initial deposit to become a member of Great Falls Federal Credit Union. This money goes on hold and can not be withdrawn until the member closes the account. Please supply your ACH Information from another financial institution so we may withdraw $25 for your initial deposit. If you decline to share this information, we require you to make the $25 initial deposit within 7 days or your account will be closed. Financial Institution Name: Routing Number: Account Number: Account Type (select one): Checking Savings Authorization & Disclaimer: By checking this box, I(We) hereby authorize GFFCU to initiate ACH (electronic fund) transfer(s) between my (our) accounts at GFFCU and my (our) account at another financial institution. Funds must be available at the time the credit entry is sent to the Federal Reserve: cut off is generally three business days prior. If the scheduled date falls on a weekend or federal holiday, I (we) understand that the transactions will be processed on the next business day. I (we) acknowledge that the origination of ACH transactions to this account must comply under the rules of the National Automated Clearing House Association (NACHA) and with the provisions of U.S. law. The authorization is to remain in full force until GFFCU has received notification from me (or either of us) of its termination in such time and manner as to afford GFFCU reasonable opportunity to act on it. A return fee may be assessed for any returned ACH transfers; GFFCU reserves the right to revoke this authorization for any returns. Your account must be in good standing for ACH authorizations to remain active. I have read and agree to Great Fall Federal Credit Union's Disclosure Agreement: I agree to the E-Signature and Electronic Disclosures Agreement and authorize Great Falls Federal Credit Union to access credit records and related information for all applicants in order to process this application. How would you like to be contacted? Phone Email Security Code: Security Code
