Countryside Federal Credit Union | P.O.Box 3247, Syracuse, NY 13220-3247
Simplified Member Sign-up (Complete & return with a minimum deposit of $5.00 to open a savings account)
Membership is open to persons who live, work, worship, or attend school in, and businesses and other legal entities located in Onondaga County, New York. -- Please make sure you have the following items completed prior to opening your account: 1-Completed Application 2-A valid drivers license, passport or non-drivers lincense (if you are mailing, please send a photocopy) and 3-$5.00 initial deposit.
Personal Information:
* means it is a Required Field

-- *Date of Birth:

*State: *Zip:
ex. 555-123-4567
ex. 555-123-4567
ex. 555-123-4567

*State:


Employment Information:

*Yrs. With Employer:
Source:
(You need not furnish Alimony,Child Support or Maintenance Income information if you do not want us to consider it in evaluating your application)

Residence Information:
Own Rent Monthly Payment: $


Your Vehicle:
Model: Year:

Name & Address of Nearest Relative Not Living With You:


Joint Applicant Information:

-- Date Of Birth:


State:


Check any Additional Services You Desire At This Time:
Direct Deposit:
Checking (Share Draft) Account:
(Line-of-Credit available to qualified members for Overdraft Protection)

VISA® ATM/Plastic Check Card
No Monthly Fee (Checking Account Required)

Internet Teller Access / Bill Paying:
Money Market Account: 		Holiday Club:
Vacation Club:
"U Name It" Club:
Share Certificate(s):
(minimum $500 deposit) Amount: $ 		Roth IRA:
Education IRA:
Traditional IRA:
Other Type of Loan Desired:
(other loan amount) Amount:
Line-of-Credit Desired Limit: $
or
Determine my Limit:
Credit Cards: For more information, disclosures, or to apply for a Countryside FCU credit card, call 800-551-0839
I hereby make application for membership in the Countryside Federal Credit Union and agree to conform to its laws and amendments thereof and subscribe for at least one share. NON-TRANSFERABLE.This application approved by the Board of Directors and entered.

The Countryside Federal Credit Union 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 said Credit Union that all sums now paid in on shares, or heretofore or hereafter paid in on shares by any or all of said joint owners to their credit as such joint owners with all accumulations thereon,are and shall be owned by them jointly with right of survivorship and be subject to withdrawal or receipt of any of them,and payment to any of them or the survivors shall be valid and discharge said Credit Union from any liability for such payment.

Any or all of said joint owners may pledge all or any part of the shares in this account as collateral security to a loan or loans.

The right of authority of the credit union under this agreement shall not be changed or terminated by said owners,or any of them except by written notice to said credit union which shall not affect transactions theretofore made.

By signing below, you certify that the information on this Account Card is complete, true, and submitted for the purpose of obtaining the accounts and services requested.You agree:(a)that the Credit Union can use credit reporting agencies or otherwise verify the information on this Account Card for the purpose of extending credit or services to you or reviewing or collecting a credit account of yours:(b)that the Credit Union can tell others about its credit experience with you and obtain information from others about your credit history and performance. If you request, the credit union will tell you the name and address of any credit reporting agency from which it received a credit report on you.

By signing below, you acknowledge receipt of, and agree to the terms of the following Agreements: •Membership and Account Agreement •Overdraft Loan Agreement •Electronic Funds Transfer Agreement •Internet Teller/Bill Paying (optional). Note: All disclosures also may be viewed on our web site at www.countryside.org.
TIN CERTIFCATION AND BACKUP WITHHOLDING INFORMATION
By signing below, I certify under penalties of perjury, that:(1)I am a U.S.person (including a U.S.resident alien); (2)the Social Security number (SSN)/taxpayer identification number (TIN)shown is my/the correct identification number; and (3)I am NOT, unless designated below, subject to backup withholding because I have not been notified that I am subject to backup withholding as a result of a failure to report all dividends or interest, or because the IRS has notified me that I am no longer subject to backup withholding. I am subject to withholding, Exempt, I am not a United States citizen or resident (complete appropriate W-8 form) The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

I will be notified of approval/denial within 24-hours of the Credit Union ’s receiving this form.I understand that the Credit Union may require additional paperwork and/or information to process this request.

Signature-Joint Owner
Date:
Signature-Owner
Date:
Office Use Only:
 
Member Number:
 
Eligibility/x-ref: 		Visa Checking Loan Add Joint Owner IRA Add Services
 
Member Group#:
 
Date:
 
Initials: