Consolidated Membership Application

Membership Application

IMPORTANT NOTICE ABOUT PROCEDURE FOR OPENING AN ACCOUNT

To help the government fight the funding of terrorism and money laundering activities, Federal Law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: when you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see you driver’s license or other identifying documents.

*Indicates a required field.

I. ELIGIBILITY I am eligible to join Financial Assurance Federal Credit Union because I am *
If you chose (A)...
Please select the company from the list
Please select one if applicable		I am a retired employee of the above selected company. I am employed by a subsidiary of the above selected company.
If you chose (B)...
Name of Relative
Relationship
Telephone Number
If you chose (C)...
Please explain further
How did you hear about us?	*
II. ACCOUNT TYPE (Check One)	*
III. MEMBER INFORMATION
First Name	*
Middle Initial
Last Name	*
Address	*
City	*
State	*
Zip	*
Social Security Number	*
Drivers License Number (N/A if not applicable)	*
Drivers License Issue State	*
Date of Birth (MM/DD/YYYY)	*
Primary Phone	*
Primary Type	*
Secondary Phone
Secondary Type
U.S. Citizen?	*	Yes No
If No, Country of Citizenship
Preferred Email Address	* Please provide an accurate Email Address, as you will be mailed important further directions !amp disclosures following the submission of this application.
Re-Enter Email Address	*
Email Type	*
Secondary Email Address
Email Type
IV. EMPLOYER INFORMATION
Employer	*
Employer Address	*
Employer City	*
Employer State	*
Employer Zip	*
Work Phone	*

V. JOINT MEMBER INFORMATION (Required if you selected Joint Account Type)

First Name
Middle Initial
Last Name
Address (if different from above)
City
State
Zip Code
Social Security Number
Date of Birth (MMDDYYYY)
Primary Phone
Primary Type
Secondary Phone
Secondary Type
U.S. Citizen?		Yes No
If No, Country of Citizenship
VI. JOINT MEMBER EMPLOYER INFORMATION
Employer
Employer Address
Employer City
Employer State
Employer Zip
Employer Email Address
Work Phone
VII. KEY WORD
Please select a 4 character KEY WORD so we can verify your identity over the phone * This is not case sensitive. May use a combination of letters and number (I.e. bank, 9765, ab12)
VIII. BENEFICIARY DESIGNATIONS (You may enter up to two)
Beneficiary 1 Full Name
Phone
Address
City
State
Zip
Date of Birth (MM-DD-YYYY)
Relationship
Beneficiary 2 Full Name
Phone
Address
City
State
Zip
Date of Birth (MM-DD-YYYY)
Relationship

PRODUCTS AND SERVICES The remainder of this application will allow you to apply for and/or order the following products and services: 1. Savings Account (required) 2. Free Checking Account 3. VISA Debit Card (Checking account required) 4. Checks (Checking account required) 5. Overdraft Protection (Checking account required) 6. ATM Card (If not applying for Checking) 7. Club Accounts (Vacation and Holiday) 8. Share Certificate of Deposit 9. Payroll Deductions/Direct Deposit

1. SAVINGS ACCOUNT (required) * I understand that this application is requesting a credit union Share Savings account. $25.00 of my initial deposit is required to be left in my Savings account at all times to secure my credit union membership.
2. FREE CHECKING ACCOUNT * Yes, I would like to apply for a Checking account with this application. No thank you, not at this time (please select No for #3 - #5 and continue with #6)
3. VISA DEBIT CARD (You must apply for a checking account to be eligible for a VISA Debit Card) * Yes, I would like a VISA Debit Card (free) with my Checking account. No thank you, not at this time (Skip ahead to #4)
3a) VISA Debit Card Design
Please select a standard card design for me Yes! I want to pick my own card design
To view Available Card Designs, copy and paste the following link into a new browser window and see Pg. 2- Card Collections (Identity Cards & Gift Cards not available): http://www.outputsolutions.fiserv.com/pdf/Fiserv_CC_Brofinal7.7.09.pdf
Design # and Style Name
3b) 24 HOUR TRANSACTION LIMITS
Default ATM limits: Number of Transactions=10 Amount of Transactions = $2,000 * Any transaction done at an ATM (Withdrawal, transfer, balance inquiry). Yes, I accept the default daily ATM limits of a maximum of 10 transactions totalling $2,000. No, I would like to customize my personal ATM limits.
ATM Dollar Amount Limit $
ATM Transaction Count Limit
Default POS (purchase) limits: Number of Transactions=20 Amount of Transactions = $5,000 * All transactions that are not done at an ATM. Yes, I accept the default daily POS limits of a maximum of 20 transactions totalling $5,000 No, I would like to customize my personal POS limits.
POS Dollar Amount Limit $
POS Transaction Count Limit
4. ORDER CHECKS * Yes, I opted to apply for a Checking Account (#2) and would like to order checks. No thank you, not at this time.
Please enter the information as you would like it to appear on your checks.
Line 1 (Suggested: Name)
Line 2 (Suggested: Street Address)
Line 3 (Suggested: City, State, Zip)
Line 4
Line 5
Shipping Address (If Different From Above)
Check Designs Brochure: Copy & Paste this link into a new browser: http://reorder.libertysite.com/
Check Style Code
Number of Boxes
Optional Accessories		Covers Wallets Stamps
Accessory Product Code(s)
5. OVERDRAFT PROTECTION (You must apply for a Checking Account [#2] to obtain Overdraft Protection). * Yes, I would like to apply for Overdraft Protection for up to $1000. No thank you, I would not like Overdraft Protection/am not applying for a Checking Account at this time.
6. ATM CARD (Savings Account Only Applicants) * If you applied for a Checking Account, please apply for a VISA Debit Card instead (#3) Yes, I would like to receive an ATM card and personal PIN to access my funds. No thank you, not at this time or I opted for a VISA Debit Card with Checking.
7. CLUB ACCOUNT (VACATION AND HOLIDAY) * Vacation Club and Holiday Club. Holiday Club only. Vacation Club only. No thank you, not at this time.
8. SHARE CERTIFICATE OF DEPOSIT * Yes, I would like to be issued a Share Certificate of Deposit (CD). No thank you, not at this time.
Share Certificate Term
Other Term
Amount
Important Note: Please mail a check in the amount of the requested Share Certificate plus the $25.00 initial deposit. The Share Certificate will not be opened until full payment is received.
9. DIRECT DEPOSIT & PAYROLL DEDUCTIONS * Yes, I would like to enroll in Direct Deposit. No thank you, I would not like to enroll in Direct Deposit at this time.
Payroll Deduction Distribution: Amount to be deducted from my salary or sick pay benefits every payday for deposit to my credit union.
Savings
Checking
Holiday Club
Vacation Club
Loan: If you are approved for a loan in the future, you may have distributions set up to make loan payments as well.
TOTAL DEDUCTION AMOUNT * Automated Field
TOTAL DEDUCTION (Automated Field=Sum of Distributions) Please note this amount for later use.
This application itself will not initiate your direct deposit. You must submit your Direct Deposit Authorization to your payroll company (This form will be emailed to you after you submit this application, or can be retrieved from the Forms & Applications section of www.fafcuny.org). Your deduction to the Credit Union will appear as a Savings deposit only in the amount of the Total Deduction above. When the funds are received, we will distribute them according to the distributions entered above.


ELECTRONIC FORM SUBMISSION AGREEMENT: By submitting this form I am verifying the following: 1)I have reviewed and am agreeing to the Membership Terms and Conditions. The Terms & Conditions will automatically be sent to the email address provided on this application upon submission, and is also available at any time on the Applications & Forms page of www.fafcuny.org. 2)The above information entered has indeed been entered by myself, the account owner or joint owner, and that submission of this form gives full authority to conduct the above requested. 3)I understand that I do have the option or right to submit this form in the paper form, which is available either through our website at www.fafcuny.org and/or upon request by contacting the credit union. 4)I understand that I exercise the right to withdraw consent to have records provided electronically, including any conditions, consequences, or fees associated with doing so. To withdraw consent I must submit written documentation with my request and verify receipt of its retrieval. 5)By entering my first and last name next to the Electronic Signature field, this stands as the equivalent of a handwritten signature. Therefore, the same laws and regulations regarding forgery apply. * Yes, I understand that by signing below, the undersigned request(s) the described services and agrees to the above mentioned terms and conditions of Electronic Form Submissions.
SIGNATURES: Primary Applicant Electronic Signature *
Date *

Joint Applicant Electronic Signature (if applicable)
Date
Why did you decide to join the Credit Union? * Table- Newport Towers (Jersey City) January 2014 Credit Union table in Charlotte, NC New Hire Orientation Referred to by a friend/colleague (give name in comment field) FAFCU Employee (give name in comment field) Past member reopening account Lowered Share Balance Minimum to $25 Facebook/Twitter Marketing email AXA Intranet Other
Comment

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THIS SECTION IS FOR THE CREDIT UNION STAFF
THIS SECTION IS FOR THE CREDIT UNION STAFF
DATE RECEIVED
APPROVED (Y/N)
UPDATED FISERV CWSI (Y/N)
UPDATED MENU 820 (Y/N)

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