Download membership enrollment application

M e m b e r s h i p E n r o l l m e n t A p p l i c at i o n
USA Patriot Act Verification - Primary Owner
USA Patriot Act Verification - Joint Owner
USA Patriot Act Verification - Joint Owner
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Origin of Discovery Enrollment Application
Origin of Discovery Enrollment Application
Origin of Discovery Enrollment Application
[ ] In Person [ ] By Mail [ ] Online [ ] Indirect Lending
[ ] In Person [ ] By Mail [ ] Online [ ] Indirect Lending
[ ] In Person [ ] By Mail [ ] Online [ ] Indirect Lending
Account Number
Identification Document Verified:
Identification Document Verified:
Identification Document Verified:
________________
[ ] Driver’s License [ ] Social Security Card [ ] Passport
[ ] Driver’s License [ ] Social Security Card [ ] Passport
[ ] Driver’s License [ ] Social Security Card [ ] Passport
[ ] Copy of DL [ ] College ID [ ] Other____________
[ ] Copy of DL [ ] College ID [ ] Other____________
[ ] Copy of DL [ ] College ID [ ] Other____________
Document No.___________________________________
Document No.___________________________________
Document No.___________________________________
Place Issued_____________________________________
Place Issued_____________________________________
Place Issued_____________________________________
Date Issued_____________________________________
Date Issued_____________________________________
Date Issued_____________________________________
Expiration Date__________________________________
Expiration Date__________________________________
Expiration Date__________________________________
Non-Document Identification______________________
Non-Document Identification______________________
Non-Document Identification______________________
________________________________________________
________________________________________________
________________________________________________
[ ] Bridger/Check Systems verification completed
[ ] Bridger/Check Systems verification completed
[ ] Bridger/Check Systems verification completed
________________________________________________
________________________________________________
________________________________________________
Employee
Employee
Employee
THIS SECTION IS FOR CREDIT UNION USE ONLY
MSR
Date
________________
Membership Officer
Date
________________
Supervisor Date
Date
Date
Date
Section 1 - Account Ownership Information
PLEASE PRINT
Name (First, Middle, Last)
Mailing Address
Date of Birth
Apt. No.
Social Security No.
City
If the above address is a PO Box, you must provide a street address for yourself.
Street Address (Street Name and Number)
State
City
Zip
State
Zip
Home Telephone No.
Evening Phone No.
Cellular Phone No.
Driver’s License No. and State
Mother’s Maiden Name
Current Employer (If self-employed list business name)
E-mail Address
Employer’s Address
Employer’s Phone No.
Section 2 - Membership Eligibility
Please select the option that best describes your eligibility for membership at Discovery:
[ ] I live, work, worship, attend school or conduct business regularly in Berks County.
[ ] I am an immediate family member of a Discovery Federal Credit Union Member. __________________________________________________________
Member’s Name
Relationship
Section 3 - Joint Owner’s Information
Joint Owner’s Name (First, Middle, Last)
Joint Owner’s Daytime Phone No.
Joint Owner’s Evening Phone No.
Joint Owner’s Address
Joint Owner’s Date of Birth
Joint Owner’s Social Security No.
Joint Owner’s Cellular Phone No.
Joint Owner’s E-mail Address
City
State
Zip
Joint Owner’s Driver’s License No. and State
2nd Joint Owner’s Information
Joint Owner’s Name (First, Middle, Last)
Joint Owner’s Daytime Phone No.
Joint Owner’s Evening Phone No.
Joint Owner’s Address
Joint Owner’s Date of Birth
Joint Owner’s Social Security No.
Joint Owner’s Cellular Phone No.
Joint Owner’s E-mail Address
City
State
Zip
Joint Owner’s Driver’s License No. and State
Section 4 - Beneficiary Payee Designation(s) Optional
In the event of my death, and all other joint owners predecease me, I hereby designate the person(s) whose name(s) appears/appear below as my beneficiary/beneficiaries to receive any and all amount in this account.
Name
Date of Birth
Social Security No.
Telephone No.
Percentage
Name
Date of Birth
Social Security No.
Telephone No.
Percentage
CONTINUED O N B A C K
Section 5 - Account and Service Options
Please select your preferred Discovery Statement delivery method.
[
] E-Statement
[ ] Paper Statement
Discovery FREE Checking
[
] Individual
[
] Joint (if checked, the joint owner(s) information in this application will be used)
Checking Overdraft Protection Plan -
Please list, in the order preferred, which Discovery account(s) you would like Discovery to transfer funds from to clear an overdraft, if it should occur. If no accounts are listed, the default
account will be your Basic Savings (S1) account. You may choose to list another member’s account if you are a joint owner of the account.
__________________________________________________________________
Account Number
__________________________________________________________________
Share Number
__________________________________________________________________
Account Number
__________________________________________________________________
Share Number
__________________________________________________________________
Account Number
__________________________________________________________________
Share Number
Standard Overdraft Practices - we do authorize and pay, at our discretion, overdrafts for checks and other transactions made using your checking account number and
automatic bill payments. We do not authorize and pay overdrafts for ATM transactions or Everyday debit card transactions. You must opt in to utilize this service.
Discovery Account Access Options
Please select the option(s) you wish to use to access your Discovery Account(s).
[
] VISA Check Card
[
] Discovery Bill Payer
[
] Discovery Online
[
] Discovery by Phone
Discovery online offers the added
security of a second level password
which will be provided upon
processing of your application.
Please choose a four-digit Personal Identification Number (PIN), which will be used
to access your Discovery Accounts using Discovery Online and Discovery by Phone.
Your Visa Check Card PIN will be mailed to you.
List any additional Discovery accounts you would like e-Service access to for the purpose of transfers to and/or loan payments to those accounts.
______________________________________
_______________________________________
Name
Account Number
______________________________________
_______________________________________
Name
Account Number
Section 6 - Certification for Taxpayer Identification Number and Account Agreement
USA Patriot Act Section 326 Customer Identification Program and New Enrollment Notice & Verification Disclosure. As required by the USA Patriot Act of 2001, which requires Discovery Federal Credit Union to help the government fight the funding
of terrorism and money laundering activities, Discovery Federal Credit Union must obtain basic identifying information from you and verify that information when you open a new account. This means Discovery Federal Credit Union will ask you for
some basic information, such as your name, address, date of birth and other information designed to help us identify you. Discovery Federal Credit Union may also ask to see documents identifying you, such as a driver’s license, passport, or some other
government-issued document. Discovery Federal Credit Union appreciates your patience and understanding as we do our part in complying with the new account identification procedures required by the federal USA Patriot Act of 2001.
> Under penalty of perjury, I/We certify that:
A. Certification of Taxpayer Identification: (1) the number on this form referenced above is my/our correct Social Security number(s)/taxpayer identification number(s) (TIN); (2) I/we am not subject to backup withholding because: (a) I/we am exempt
from backup withholding; or (b) I/we have not been notified by the Internal Revenue Service (IRS) that I/we am subject to withholding as a result of a failure to report all interest or dividends; (c) the IRS has notified me/us that I/we am no longer subject to
withholding; and (3) I/we am a U.S. citizen or resident alien.
Note: Cross out item (2) above if you have been notified by the IRS that you are currently subject to backup withholding.
B: Account Agreement: I/we certify the above information to be true and complete. I/we hereby apply for membership in the Discovery Federal Credit Union, and agree to conform to its bylaws and amendments thereof, copies of which have been
made available to me/us, and subscribe for at least one (1) share. I/we authorize any person, association, firm, and corporation or personnel office to furnish information concerning me/us or my/our affairs upon request of Discovery Federal Credit Union.
Further, I/we have read all account and membership disclosures and information and acknowledge receipt of a copy of all agreements and disclosures applicable to the accounts and services requested.
The IRS does not require consent to any provisions of this document other than the certification required to avoid backup withholding. Free Checking Disclosure and Commitment. By signing this enrollment application and providing the requested
information for a checking account, I/we hereby request the Discovery FCU to establish a regular S4 checking account for me/us, and all joint owners of this account, and agree to be bound by the bylaws, rules, and regulations of Discovery FCU.
E-Service Disclosure and Commitment. By signing this enrollment application and providing the requested information for e-services, I/we understand that a copy of the full Discovery FCU Electronic Services Agreement and Disclosure is available
by calling or visiting the credit union office and that I/we may obtain a copy at no cost without obligation to apply for Electronic Access Services at any time. I/we agree to abide by the terms and conditions of the Electronic Services Agreement and
Disclosure. I/we also acknowledge receipt of the disclosure statement information me/us of my/our rights under the Electronic Funds Transfer Act and the Truth-in-Savings Acts, as applicable. I/we understand DFCU may terminate this agreement at any
time. By completing this application, I/we agree to read the Electronic Services Agreement and Disclosure and agree to abide by the terms and conditions of the agreement.
Joint Account Holder Agreement. By signing this enrollment application and providing the requested information for a Joint account, Discovery FCU is hereby authorized to recognize any of the signatures subscribed hereto in the payment of funds
or the transaction of any business for this account. The joint owners of this account hereby agree with each other and with Discovery FCU that all sums now paid in on shares, or heretofore or hereafter paid in shares by any or all said joint owners to their
credit as such owners with all accumulations thereon, are and shall be owned by them jointly, with right of survivorship and be subject to the withdrawal or receipt of any of them, and payment to any of them or the survivor or survivors shall be valid and
discharge Discovery FCU from any liability for such payment. The joint owners also agree to the terms and conditions of the account as established by the credit union. Any or all said joint owners may pledge all or any part of the shares in this account
as collateral security to a loan or loans from this credit union. The right or authority of the credit union under this agreement shall be changed or terminated by said owners, or any of them except by written notice to Discovery FCU which shall not affect
transactions theretofore made.
E-Statement Disclosure and Commitment. By signing this enrollment application and agreeing to accept e-Statements, I/we acknowledge that we will receive an e-mail each time my/our statement is processed indicating that my/our e-Statement
is ready for viewing on Discovery FCU’s secure server. An e-Statement is in lieu of a paper statement. The e-mail will contain a link to my/our e-Statement login page. My/our e-Statement will be available at https://www.lastertec-mi.com/discoveryfcu by
entering my/our user ID.
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Signature of Primary Owner (Please do not print)
Date
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_________________________________________________________________________________________________________________
Signature of Joint Owner (If Applicable)
Date
X
_________________________________________________________________________________________________________________
Signature of Joint Owner (If Applicable)
Date
T H A N K Y O U F O R C H O O S I N G D I S C O V E R Y.