Membership Application

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW 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 your driver�s license or other identifying documents.

Confidentiality of this information will be maintained as required under the Privacy Act and all other applicable laws and regulations.

Membership Application

Please provide all the requested information. When you have completed the form, press the Submit button to send your application. If necessary, we will contact you for additional information.

The items marked with (*) are required fields.

General Information
. Will there be a co-applicant on this application? No Yes, 1 co-applicant Yes, 2 co-applicants (If Yes, the co-applicant section has the same required fields as the primary applicant.)
Membership Eligibility *I am eligible for membership through:
Employer	(Employer Name)
Family Member	(Family Members Name)

Primary Applicant
*Last Name
*First Name
Middle Name
Social Security #
Date of Birth
*Home Phone Number	- .-.
Work Phone Number	-.-. ext. .
. Number	-.-. ext. .
Email Address

. I certify that: The TIN is correct and I AM / AM NOT subject to back-up withholding and I am a U.S. Person (including a U.S. Resident Alien).

Drivers License #
Drivers License State

Mother's Maiden Name

Home Address (not P.O. Box)
*Address 1
Address 2
*City
*State
*Zip	-.
Time at Current Residence	Years Months
Residence Type	. Own Rent Other .

Mailing Address (if different)
Address 1
Address 2
City
State
Zip	-.

Employment History
Present Employer Name
Employer Phone Number	-.-. ext.
Job Title
Job Start Date	/./.
Employer's Address
Address 1
Address 2
City
State
Zip	-.

Co-Applicant 1 (if applicable)
Last Name
First Name
Middle Name
Relationship to Primary Owner
Social Security Number (TIN)	-.-.
Date of Birth	/./.
Home Phone Number	-.-.
Work Phone Number	-.-. ext.
. Number	-.-. ext.
Email Address

Drivers License #
Drivers License State

Mother's Maiden Name

Home Address (not P.O. Box)
Address 1
Address 2
City
State
Zip	-.
Time at Current Residence	Years Months
Residence Type	. Own Rent Other .

Mailing Address (if different)
Address 1
Address 2
City
State
Zip	-.

Employment History
Present Employer Name
Employer Phone Number	-.-. ext.
Job Title
Job Start Date	/./.
Employer's Address
Address 1
Address 2
City
State
Zip	-.

Co-Applicant 2 (if applicable)
Last Name
First Name
Middle Name
Relationship to Primary Owner
Social Security Number (TIN)	-.-.
Date of Birth	/./.
Home Phone Number	-.-.
Work Phone Number	-.-. ext.
. Number	-.-. ext.
Email Address

Drivers License #
Drivers License State

Mother's Maiden Name

Residence Address (not P.O. Box)
Address 1
Address 2
City
State
Zip	-.
Time at Current Residence	Years Months
Residence Type	Own Rent Other .

Mailing Address (if different)
Address 1
Address 2
City
State
Zip	-.

Employment History
Present Employer Name
Employer Phone Number	-.-. ext.
Job Title
Job Start Date	/./.
Employer's Address
Address 1
Address 2
City
State
Zip	-.

References
Nearest relative Not Living With You
Last Name
First Name
Relationship
. Number	-.-. ext.
Address 1
Address 2
City
State
Zip	-.

Additional Information
How would you prefer to be contacted? . Home Phone Work Phone Cell Phone Email Address Other .
Special Instructions/Comments .
The Internal Revenue Service does not require your consent to any provision of this contract other than the certifications required to avoid backup withholding.

Your savings are Federally insured up to at least $250,000

Boston Customs Federal Credit Union is federally insured by the National Credit Union Administration

Unauthorized Access is Prohibited. All Accesses are Monitored.