CFCU Membership Application

Fields marked with * are required

	Will there be a co-applicant on this application? No Yes *Membership Eligibility (Must enter information for AT LEAST ONE of the fields below) I am eligible for membership through: Employer Name Family Member's Name Community Name APPLICANT INFORMATION *Last Name: *First Name: Middle Name: *SSN: *Date of Birth: (MM-DD-YYYY) Email: *Home Phone: Work Phone: I certify that: The TIN is correct and I AM / AM NOT subject to back-up withholding and I am a U.S. Person (including a U.S. Resident Alien). *DL Number: *State: Alabama Alaska Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming DL Expiration (MM-DD-YYYY): *Home Address: (not P.O. Box) Apt: City: State: Alabama Alaska Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Zip: *Years at Address: * Own Rent Mailing Address: (If different) Apt: City: State: Alabama Alaska Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Zip: Employer's Name and Address: Name: Address: Apt: City: State: Alabama Alaska Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Zip: Phone: Additional Information How would you prefer to be contacted? Home Phone Work Phone Email Address Other Special Instructions/Comments The Internal Revenue Service does not require your consent to any provision of this contract other than the certifications required to avoid backup withholding.