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·V1DPH BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB and my anticipated graduation date will be ______ 5HODWLRQVKLS BB 3DUHQW*UDQGSDUHQW BB &KLOG*UDQGFKLOG BB 6SRXVH BB 6LEOLQJ BB5HVLGHLQVDPHKRXVHKROG ,VWKLVD36(&8HPSOR\HH"BB APPLICANT INFORMATION JOINT OWNER ______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/,&$7,21 I/We apply for membership in PSECU and agree to the conditions stated on this application and in the Agreements & Disclosures and the Bylaws, rules and regulations of PSECU which will be provided to me/us as required by law. I/We apply for and agree to the stated terms for each service requested on this application. From time to time, PSECU will announce additional services. My/Our use of these services will indicate P\RXUDFFHSWDQFHRIWKHWHUPVDQGFRQGLWLRQVSUHVHQWHGDVWKH\DUHDQQRXQFHG,:HDXWKRUL]HDQ\SHUVRQDVVRFLDWLRQÀUPFRUSRUDWLRQFUHGLWEXUHDXRUSHUVRQQHORIÀFHWRIXUQLVKLQIRUPDWLRQLQFOXGLQJFUHGLW reports, concerning me/our or my/our affairs and all joint owners upon request of this credit union. I/We understand that I/we and any or all of my/our joint owners have the right to request in writing, the nature and scope of the credit union’s investigation. Any negative balance created in this account shall bear interest at the highest unsecured loan rate offered by PSECU until paid in full. Repayment of this amount will be the personal obligation of all joint owners of any account owned by those individuals. I/We understand that it is a federal crime to willfully or negligently provide incomplete or incorrect information on requests made to State Chartered Credit Unions insured by the National Credit Union Administration. I/We understand that PSECU will rely on all the information in this membership application to ensure membership eligibility. I/We certify under penalty Title 18, United States Code, Section 1001, et seq. that the information on this application is true and correct. 7KH,QWHUQDO5HYHQXH6HUYLFHGRHVQRWUHTXLUH\RXUFRQVHQWWRDQ\ SURYLVLRQRIWKLVGRFXPHQWRWKHUWKDQWKHFHUWLÀFDWLRQVUHTXLUHGWRDYRLGEDFNXSZLWKKROGLQJ5HDGWKH,QWHUQDO5HYHQXH6HUYLFH: )RUPEHORZDQGFRPSOHWHLIDSSOLFDEOH ______/______/______APPLICANT’S SIGNATURE 3OHDVHVLJQLQLQN PRINT SIGNATURE DATE ______/______/______JOINT OWNER’S SIGNATURE 3OHDVHVLJQLQLQN PRINT SIGNATURE DATE 0HPEHUVKLSDSSOLFDWLRQH[SHQVHV$QRQUHIXQGDEOHHQWUDQFHIHHZLOOEHZDLYHG$PLQLPXPVKDUHSXUFKDVHZLOOEHPDGHRQEHKDOIRIWKHPHPEHUE\36(&8,IWKHPHPEHUDFFRXQWLVFORVHGZLWKLQWKHÀUVW year of membership, the initial $5 share will be retained by PSECU. In order to retain membership in the credit union, members must maintain a $5 share in the credit union. If you are sending additional funds, please indicate how you wish your money to be distributed. Send application and your check, if needed to 36(&8$WWQ $SSOLFDWLRQ3URFHVVLQJ'HSW32%R[ +DUULVEXUJ3$ $ ______5(*8/$56+$5(6 6 ______CHECKING/TRANSACTIONAL SHARES (S4) PROMOTIONAL CODE ______REFERRAL CODE ______ W-9 FORM - INTERNAL REVENUE SERVICE TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION 3ULPDU\$SSOLFDQW2QO\ 8QGHUSHQDOWLHVRISHUMXU\,FHUWLI\WKDW L ,DPD86&LWL]HQRU5HVLGHQW LL WKH6RFLDO6HFXULW\1XPEHU 661 7D[SD\HU,GHQWLÀFDWLRQ1XPEHU 7,1 VKRZQRQWKLVIRUPLVP\ FRUUHFWLGHQWLÀFDWLRQQXPEHUDQG LLL ,DP127XQOHVVGHVLJQDWHGEHORZVXEMHFWWREDFNXSZLWKKROGLQJDVDUHVXOWRIDIDLOXUHWRUHSRUWDOOGLYLGHQGVRULQWHUHVWRUEHFDXVHWKH ,56KDVQRWLÀHGPHWKDW,DPQRORQJHUVXEMHFWWREDFNXSZLWKKROGLQJ ,DPVXEMHFWWREDFNXSZLWKKROGLQJ If you are a foreign person (not a U.S. citizen or resident), please print, complete and return form W-8BEN to us with any required documents. $Q\ÀQDQFLDOVHUYLFHSURYLGHGE\36(&8PD\EHXVHGIRUDQ\WUDQVDFWLRQSHUPLWWHGE\ODZ USA PATRIOT ACT IDENTITY VERIFICATION NOTICE ,PSRUWDQWLQIRUPDWLRQDERXWSURFHGXUHVIRURSHQLQJDQHZ36(&8DFFRXQW 7RKHOSRXUJRYHUQPHQWÀJKWWKHIXQGLQJRIWHUURULVPDQGVWRSPRQH\ODXQGHULQJDFWLYLWLHV)HGHUDOODZUHTXLUHVDOOÀQDQFLDOLQVWLWXWLRQVLQFOXGLQJ36(&8WRREWDLQYHULI\DQG UHFRUGLQIRUPDWLRQWKDWLGHQWLÀHVHDFKSHUVRQZKRRSHQVDQDFFRXQW :KDWWKLVPHDQVIRU\RX :KHQ\RXRSHQDQDFFRXQWZHZLOODVNIRU\RXUQDPHDGGUHVVGDWHRIELUWK7D[SD\HU,GHQWLÀFDWLRQ1XPEHU 7,1 XVXDOO\\RXU6RFLDO6HFXULW\ Number) and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying document(s). The law requires us to maintain UHFRUGVRIWKHLGHQWLÀFDWLRQYHULÀFDWLRQDQGSHULRGLFDOO\XSGDWHWKLVLQIRUPDWLRQ 3OHDVHEHDVVXUHGWKDWWKHVDPHVWULFWFRQÀGHQWLDOLW\RI\RXULQIRUPDWLRQPDLQWDLQHGE\PSECU will be continued as required under the *UDPP/HDFK%OLOH\3ULYDF\$FW and 36(&8·V3ULYDF\3ROLF\. 3ROLWLFDOO\([SRVHG3HUVRQ The expression “politically exposed person” (“PEP”) applies to persons, their families, and close associates who perform important public functions for a foreign country, which would include a Senior Foreign Political Figure. ([DPSOHVRI´3ROLWLFDOO\([SRVHG3HUVRQVµ +HDGVRIVWDWH IRUHLJQFRXQWULHV FDELQHWPLQLVWHUVSROLWLFDOSDUW\OHDGHUVLQÁXHQWLDOH[HFXWLYHVLQQDWLRQDOL]HGLQGXVWULHVRUXQGHUJRYHUQPHQWDGPLQLVWUDWLRQVHQLRU MXGLFLDORUPLOLWDU\RIÀFLDOVDQGPHPEHUVRIUXOLQJIDPLOLHVDPRQJRWKHUV PROFESSION/JOB TITLE $FFRPPRGDWLRQDQG)RRG6HUYLFHV 3URIHVVLRQDO6FLHQWLÀ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© PSECU 12-UNGNAD-0904