SEG Form

Name of Organization	*
Type of Organization		Non Profit For Profit
Address	*
City	*
State / Province	*
Zip / Postal	*
Requesting Membership for how many individuals?
Nature of Business
Are your employees eligible for membership at another credit union?
Contact Information
Primary Contact / Decision Maker	*
Phone Number	*
Email Address	*
Best Method of Contact		Phone Email
Comments
Security Code	*