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PSECU MEMBERSHIP APPLICATION Millersville University

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Intern Number FOR INTERNAL USE ONLY Account Number ______________________________________ Teller Number __________________ Date __________________ ©PSECU Form # 2062 11/12 PSECU MEMBERSHIP APPLICATION Millersville University Complete application with ball point pen. For non-U.S. citizens, in addition to the ID documents, please provide copies of your documentation of citizenship VWDWXV HQWU\GRFXPHQWVUHFHLYHGXSRQDUULYDOLQWKH86RURWKHUGRFXPHQWDWLRQRISHUPDQHQWVWDWXVFKDQJH DORQJZLWKDSSURSULDWHWD[FHUWLÀFDWLRQ 6RFLDO Security card and/or W-8BEN). For current rates, fees and the Truth in Savings Account Disclosures, visit psecu.com/rates or call 800.237.7328. APPLICANT ELIGIBILITY &KHFNRQH ÀOOLQHOLJLELOLW\ I AM A STUDENT – 3022 I AM A FAMILY MEMBER – 3025 My grade level is __ Freshman __ Sophomore __ Junior __ Senior 36(&80HPEHU·V1DPHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB and my anticipated graduation date will be ________________________________________________ 5HODWLRQVKLS BB 3DUHQW*UDQGSDUHQW BB &KLOG*UDQGFKLOG BB 6SRXVH BB 6LEOLQJ BB5HVLGHLQVDPHKRXVHKROG ,VWKLVD36(&8HPSOR\HH"BB<HVBB1R I AM A FACULTY/STAFF MEMBER – 3026 APPLICANT INFORMATION JOINT OWNER <RXPXVWEHDWOHDVW\HDUVRIDJHWREHDQDFFRXQWRZQHU <RXPXVWEHDWOHDVW\HDUVRIDJHWREHDMRLQWRZQHU$OOMRLQWRZQHUVDJUHHWREH ERXQGE\WKHWHUPVVWDWHGLQWKH6LJQDWXUH6HFWLRQDQGWKH-RLQW2ZQHU$JUHHPHQW LQFOXGHGLQWKH$JUHHPHQWVDQG'LVFORVXUHVERRNOHWZKLFKZLOOEHSURYLGHG _____________________________________________________________________________ SOCIAL SECURITY # OR TAX ID # (If you’re under 18, please also provide a copy of your Social Security Card.) RELATIONSHIP TO APPLICANT (OWNER) BBB$GXOW)DPLO\0HPEHUBBB&KLOG6WHS&KLOG _____________________________________________________________________________ FIRST NAME, MIDDLE INITIAL, LAST NAME, SUFFIX BBB*UDQGFKLOGBBB*UDQGSDUHQWBBB3DUHQW6WHS3DUHQWBBB6LEOLQJBBB6SRXVH BBB6DPH+RXVHKROGBBB1RW$SSOLFDEOH _____________________________________________________________________________ E-MAIL ADDRESS _____________________________________________________________________________ _____________________________________________________________________________ SOCIAL SECURITY # OR TAX ID # (If you’re under 18, please also provide a copy of your Social Security Card.) HOME PHONE NUMBER _____________________________________________________________________________ _____________________________________________________________________________ FIRST NAME, MIDDLE INITIAL, LAST NAME, SUFFIX WORK PHONE NUMBER _____________________________________________________________________________ _____________________________________________________________________________ E-MAIL ADDRESS CELL PHONE NUMBER _____________________________________________________________________________ PREFERRED METHOD OF CONTACT ___ E-mail ___ Home ___ Work ___ Cell HOME PHONE NUMBER DATE OF BIRTH: _______/_______/_______ _____________________________________________________________________________ WORK PHONE NUMBER PLEASE SELECT ONE BOX BELOW: _____________________________________________________________________________ I am a U.S. citizen. CELL PHONE NUMBER I am a permanent resident alien. PREFERRED METHOD OF CONTACT ___ E-mail ___ Home ___ Work ___ Cell I am not a U.S. citizen or permanent resident alien. DATE OF BIRTH: _______/_______/_______ _____________________________________________________________________________ PROFESSION/JOB TITLE NUMBER 6HHSDJHWRÀQGWKH3URIHVVLRQ-RE7LWOH1XPEHUWKDWEHVW PLEASE SELECT ONE BOX BELOW: describes your occupation.) I am a U.S. citizen. I am a permanent resident alien. __________________________________________________________________________ DRIVER’S LICENSE # OR GOVERNMENT-ISSUED ID # (If you do not have a driver’s license or I am not a U.S. citizen or permanent resident alien. JRYHUQPHQWLVVXHGSKRWR,'SOHDVHVXEPLWFRSLHVRI,'RQHUHÁHFWLQJFXUUHQWDGGUHVV _____________________________________________________________________________ _______________________ _______/_______/_______ _______/_______/_______ PROFESSION/JOB TITLE NUMBER 6HHSDJHWRÀQGWKH3URIHVVLRQ-RE7LWOH1XPEHUWKDWEHVW STATE ISSUE DATE EXPIRATION DATE describes your occupation.) ____________________________________________________________________________ PERMANENT STREET ADDRESS ,IDGGUHVVLVD3RVW2IÀFH%R[DOVROLVWWKHSODFHRIUHVLGHQFH _____________________________________________________________________________ DRIVER’S LICENSE # OR GOVERNMENT-ISSUED ID # (If you do not have a driver’s license or ___________________________________________________________________________ JRYHUQPHQWLVVXHGSKRWR,'SOHDVHVXEPLWFRSLHVRI,'RQHUHÁHFWLQJFXUUHQWDGGUHVV CITY, STATE, ZIP _______________________ _______/_______/_______ _______/_______/_______ OCCUPANCY STATUS BB%X\LQJ2ZQZLWK0RUWJDJHBB*RYHUQPHQW4XDUWHUV STATE ISSUE DATE EXPIRATION DATE BB/LYHZLWK3DUHQWVBB2ZQ²)UHH &OHDUBB5HQWBB2WKHU _____________________________________________________________________________ HOW LONG AT THIS ADDRESS? _______________________ PERMANENT STREET ADDRESS ,IDGGUHVVLVD3RVW2IÀFH%R[DOVROLVWWKHSODFHRIUHVLGHQFH If less than 2 years, list previous address ______________________________________________ _____________________________________________________________________________ CITY, STATE, ZIP _____________________________________________________________________________ OCCUPANCY STATUS BB%X\LQJ2ZQZLWK0RUWJDJHBB*RYHUQPHQW4XDUWHUV ARE YOU A POLITICALLY EXPOSED PERSON (PEP)? __ Yes __ No BB/LYHZLWK3DUHQWVBB2ZQ²)UHH &OHDUBB5HQWBB2WKHU 6HHSDJHIRUPRUHLQIRUPDWLRQUHJDUGLQJ3ROLWLFDOO\([SRVHG3HUVRQV HOW LONG AT THIS ADDRESS? _______________________ ARE YOU A CLOSE ASSOCIATE OR FAMILY MEMBER OF A PEP? __ Yes __ No If less than 2 years, list previous address ______________________________________________ DO YOU ALSO LIVE IN A FOREIGN COUNTRY? __ Yes __ No _____________________________________________________________________________ EMPLOYMENT STATUS: BB(PSOR\HGBB8QHPSOR\HGBB5HWLUHGBB+RPHPDNHU __ Student __ Minor __ Disabled ARE YOU A POLITICALLY EXPOSED PERSON (PEP)? __ Yes __ No 6HHSDJHIRUPRUHLQIRUPDWLRQUHJDUGLQJ3ROLWLFDOO\([SRVHG3HUVRQV ARE YOU A CLOSE ASSOCIATE OR FAMILY MEMBER OF A PEP? __ Yes __ No DO YOU ALSO LIVE IN A FOREIGN COUNTRY? __ Yes __ No EMPLOYMENT STATUS: BB(PSOR\HGBB8QHPSOR\HGBB5HWLUHGBB+RPHPDNHU __ Student __ Minor __ Disabled COMPLETE YOUR PIN/PASSWORD DO NOT DETACH 6HOHFW3,1VDQGDSDVVZRUGWKDWDUHQRWHDVLO\LGHQWLÀHGZLWK\RXVXFKDV\RXU6RFLDO6HFXULW\QXPEHU3OHDVHGRQRW use symbols, numbers between 0000 and 0009, repeating numbers (1111, 2222, etc.), or consecutive ascending or descending numbers (1234, 4321, for example). Please select different PINs and write them in the spaces below. Please note them for your reference. 36(&8GRHVQRWNHHS\RXU3,1VRQÀOH You will need your PSECU Member Account PIN when contacting us. YOUR MEMBER ACCOUNT PIN: YOUR CHECK CARD/ATM PIN: ONLINE BANKING PASSWORD: 3DVVZRUGPXVWEHFKDUDFWHUVDQGPXVWFRQWDLQRQHQXPEHURQHXSSHUFDVHOHWWHUDQGRQHORZHUFDVHOHWWHU6SHFLDOFKDUDFWHUVDUHDOORZHGEXWQRWUHTXLUHG7KHÀUVWIRXUFKDUDFWHUVFDQQRWEHWKHVDPH P.O. BOX 67013, HARRISBURG, PA 17106-7013 800.237.7328 6((5(9(56(72&203/(7($33/,&$7,21 <28:,//5(&(,9($'',7,21$/$*5((0(17$1'',6&/2685(0$7(5,$/663(&,),&727+(352'8&76<285(48(67 CHECKING CHECK CARD YES,ZDQWFKHFNLQJVHUYLFHVDQGSDSHUFKHFNV (QWHU\RXU3,1LQWKHVSDFHSURYLGHGRQWKLVDSSOLFDWLRQ Your checking will automatically overdraft from Regular Shares (S1). The basic-style checks you receive are YES,ZDQWD&KHFN&DUG &KHFN&DUGFDQEHXVHGIRU$70VHUYLFHV free. Your name and address will appear on your checks. Please allow two weeks to receive your checks. ___ Add my home phone number ___ 1 Check Card in my name ___ 2 Check Cards in my name ___ Add my joint owner’s name ___ 2 Check Cards, 1 in my name and 1 in my joint owner’s name ONLINE BANKING Your Check Card will automatically overdraft from Regular Shares (S1). However, overdrafting will not DSSO\DWWKHWLPHRISXUFKDVH6XIÀFLHQWIXQGVPXVWEHDYDLODEOHLQ\RXU&KHFNLQJ7UDQVDFWLRQDO6KDUHV (QWHU\RXUGLJLWSDVVZRUGLQWKHVSDFHSURYLGHGRQWKLVDSSOLFDWLRQ (S4) for your purchase to be authorized. Overdrafting will apply at the time your purchase is presented to PSECU for payment. Please allow two weeks to receive your Check Card. YES,ZDQWRQOLQHEDQNLQJ SIGNATURES 3/($6(5($'0$7(5,$/&$5()8//<$//$33/,&$176$5(5(48,5('726,*17+($33/,&$7,21 I/We apply for membership in PSECU and agree to the conditions stated on this application and in the Agreements & Disclosures and the Bylaws, rules and regulations of PSECU which will be provided to me/us as required by law. I/We apply for and agree to the stated terms for each service requested on this application. From time to time, PSECU will announce additional services. My/Our use of these services will indicate P\RXUDFFHSWDQFHRIWKHWHUPVDQGFRQGLWLRQVSUHVHQWHGDVWKH\DUHDQQRXQFHG,:HDXWKRUL]HDQ\SHUVRQDVVRFLDWLRQÀUPFRUSRUDWLRQFUHGLWEXUHDXRUSHUVRQQHORIÀFHWRIXUQLVKLQIRUPDWLRQLQFOXGLQJFUHGLW reports, concerning me/our or my/our affairs and all joint owners upon request of this credit union. I/We understand that I/we and any or all of my/our joint owners have the right to request in writing, the nature and scope of the credit union’s investigation. Any negative balance created in this account shall bear interest at the highest unsecured loan rate offered by PSECU until paid in full. Repayment of this amount will be the personal obligation of all joint owners of any account owned by those individuals. I/We understand that it is a federal crime to willfully or negligently provide incomplete or incorrect information on requests made to State Chartered Credit
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