Lanier Federal Credit Union
LANIER
MEMBER APPLICATION & AGREEMENT
MEMBER INFORMATION
Name _________________________________________________________________________________________ 
Address/City/State/Zip__________________________________________________________________________    
SSN/TIN ______________________________________ Phone________________________________
Date of Birth ______________________
Driver's Lic. # ___________________ MMN_________________
Present Employer(name & address)______________________________________________________________
__________________________________________________________
Phone_______________________
I qualify for membership in this Credit Union because_____________________________________________

Name and address of someone who will always know your location _________________________________

_______________________________________________________________________________________________
JOINT OWNERS/MINOR INFORMATION
Name _________________________________________________________________________________________
Address/City/State/Zip__________________________________________________________________________    
SSN/TIN ______________________________________ Phone________________________________
   
Date of Birth ______________________
Driver's Lic. # ___________________ MMN__________________
Name _________________________________________________________________________________________ 
Address/City/State/Zip__________________________________________________________________________    
SSN/TIN ______________________________________ Phone________________________________
Date of Birth ______________________
Driver's Lic. # ___________________ MMN__________________
OWNERSHIP OF ACCOUNT
SELECT ONE OWNERSHIP TYPE AND, IF APPLICABLE, INCLUDE A BENEFICIARY DESIGNATION. THE OWNERSHIP TYPE AND BENEFICIARY DESIGNATION SPECIFIED ON THIS DOCUMENT WILL REMAIN THE SAME FOR ALL ACCOUNTS LISTED BELOW.
1. INDIVIDUAL 2. JOINT WITH SURVIVORSHIP (and not as tenants in common)
3. MEMBER AS CUSTODIAN FOR MINOR UNDER THE GEORGIA TRANSFERS TO MINORS ACT (GTMA)
4. TRUST - SEPARATE AGREEMENT DATED ____________________________________________________
5. ________________________________________________________________________________________
BENEFICIARIES:
REVOCABLE TRUST OR PAY-ON-DEATH DESIGNATION AS
DEFINED IN THE ACCOUNT TERMS AND CONDITIONS: (Place name and address of beneficiaries below.)
___________________________________________
___________________________________________
___________________________________________ ___________________________________________
ACCOUNT TYPE
___________________________________________ ___________________________________________
___________________________________________ ___________________________________________
___________________________________________ ___________________________________________
Number of signatures required for withdrawal ________. This is a temporary account agreement.
SIGNATURES & CERTIFICATIONS
BACKUP WITHHOLDING CERTIFICATION - Check box (A) only if true or (B) below:
(A)
By signing below, I (name) _____________________________________________________________
certify under penalties of perjury that (1) the Taxpayer Identification Number (TIN) shown above is my correct TIN and I am not subject to bakcup withholding either because (a) I have not been notified by the Internal Revenue Service that I am subject to backup withholding as a result of a failure to report all interest or dividends or (b) the IRS has notified me that I am no longer subject to backup withholding.
(B)
A separate Certification has been completed.
By signing below, the undersigned agree to the Credit Union by-laws and the terms and conditions of any approved account, as ammended from time to time, and authorize the Credit Union to verify credit and employment history by any necessary means, including preparation of a credit report by a credit reporting agency. The undersigned certify that the information provided on this application is true and correct and that the terms on this application apply to all listed accounts. The undersigned acknowledg receipt of a copy of the terms and conditions applicable to each listed account and the following policy disclosures:
Funds Availability Truth-In-Savings Electronic Fund Transfers __________________
THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING.
(2) X

_______________________________________ Member Signature

_____________________
(Date)
______________________
Member/Account #
(2) X

_______________________________________ Signature

_____________________
(Date)
______________________
Relationship to Member
(3) X

_______________________________________ Signature

_____________________
(Date)
______________________
Relationship to Member
AGENTS - THE INDIVIDUAL SIGNING ABOVE ON LINE _________________ IS SIGNING AS:
Power of Attorney-agreement on file A Successor Custodian of a GTMA account Parent/Guardian
Authorized Signer __________________________________________________
CREDIT UNION USE ONLY
ACCT. TITLE __________________________________________________________________________________
ACCT. SERVICES ______________________________________________________________________________
INITIAL AMOUNT $___________________ FORM: CASH ____________________________
APPLICATION APPROVED (date) _____________________________ BY _______________________________


You Must Print, Sign, and Mail or Fax to:

Lanier Federal Credit Union
3718 Mundy Mill Rd
Oakwood, GA 30566
(770) 503-1865 (fax)

 
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