Membership Application

“IMPORTANT INFORMATION ABOUT THE 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 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 you 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 information.”

* Required Fields

Name:

Application For Membership and Share Account Agreement With Beneficiary Option

Part I: Ownership Information

I/We submit this form to the Integra First Federal Credit Union for two purposes. First, the individual listed as Owner Name (1) below (unless already a member) applies for membership in the credit union. Second. I/We request the credit union to open a share account in the owner name(s) listed below. If more than one owner name is listed below, the account shall be a multiple name share account and the multiple name account provisions of this agreement shall be applicable. If one or more beneficiaries are listed in the Beneficiary Information and Provisions section (Part V), the beneficiary provisions of this agreement shall be applicable.

Owner Name (1):

Address:

Address 2:

City:

State:

ZIP:

Home Phone Number:

Cell Phone Number:

Work Phone Number:

Email Address:

Date of Birth:

/ /

Mother's Maiden Name:

Driver's License No.:

Soc. Sec. No.:

- -

Other ID used to establish account:

Eligibility based on (If family relationship, specify type of relationship and name of family member.):

Owner Name (2):

Address:

Address 2:

City:

State:

ZIP:

Home Phone Number:

Cell Phone Number:

Work Phone Number:

Email Address:

Date of Birth:

/ /

Mother's Maiden Name:

Driver's License No.:

Soc.Sec. No.:

- -

Other ID used to establish account:

Owner Name (3):

Address:

Address 2:

City:

State:

ZIP:

Email Address:

Date of Birth:

/ /

Mother's Maiden Name:

Driver's License No.:

Other ID used to establish account:

Part II: IRS CERTIFICATION

Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued), and (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and (3) I am a U.S. person (including a U.S. resident alien), and (3) I am a U.S. citizen or other U.S. person. For federal tax purposes, you are considered a U.S. person if you are: an individual who is a U.S. citizen or U.S. resident alien; a partnership, corporation, company, or association created or organized in the United States or under the laws of the United States; an estate (other than a foreign estate); or a domestic trust (as defined in Regulations section 301.7701-7) and (4) The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Complete a W -8 BEN if you are not a U.S. person. If a W -8 BEN is completed, your signature does not serve to certify this section.

Part III: TERMS AND CONDITIONS OF ACCOUNT

The following terms and conditions apply to this account.

a. All sums paid to the credit union on shares (less setoffs allowed by law and/or provided for by contract) shall be paid on proper withdrawal demand. In this case of a single name account, such demand must be made by one or more of his/her representative. In the case of a multiple name account, such demand must be made by one or more of the owners of the account and in accordance with the initialed agreement regarding signatures or, in the absence of such initials, by any one owner. If all owners are deceased and there is a beneficiary(ies) listed in this agreement, withdrawals may be made by the beneficiary(ies) according to the beneficiary provisions set out below (Part V).

b. Only methods approved by the credit union may be used to make withdrawals from this account.

c. All non-cash payments received in this account will be credited subject to final payment.

d. Any objection respecting any item shown on a periodic statement of this account is waived unless made in writing to the credit union before the end of 60 days after the statement is mailed.

e. This account is subject to the credit union's right to require advance notice of withdrawal, as provided in the credit union's bylaws.

f. This account is also subject to such other terms and conditions as the credit union may establish from time to time. The credit union may change the terms and conditions of this account upon giving a 30-day advance written notice. Notice may be given by U.S. Mail, first class, postage prepaid, to my/our last known address, as reflected in the credit union's records.

Signature required

Part IV: MULTIPLE NAME ACCOUNT AGREEMENT

The joint owner of this account hereby agree with each other and with the credit union that all sums now paid into this account, by any or all of said joint owners with all accumulations thereon, are and shall be owned by them jointly, with right of survivorship, and shall be subject to withdrawal or receipt of any of them, except to the extent an initialed restriction below applies. Payment in accordance with such a proper demand shall be valid and discharge the credit union from any liability for such payment. The credit union is hereby authorized to recognize the signature(s) subscribed above, in accordance with the restrictions initialed below, in the payment of funds or the transaction of any business for this account. However, no individual may be removed as an owner of this account, except upon death, without the individual's consent. No beneficiary of this account may be changed except with the consent of all living owners.

The right or authority of the credit union under this agreement shall not be changed by any owners, except by written notice to the credit union. Such notice shall not affect any transactions made prior to receipt of the notice by the credit union.

Please Read Disclosure Before Submitting 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.

PRIVACY STATEMENT:

It is the policy of Integra First Federal Credit Union that all personal information supplied to the credit union by our members via the Internet will remain completely confidential. The credit union will use personal information only as required to transact credit union related business between Integra First Federal Credit Union and our members. Integra First Federal Credit Union will not sell or otherwise distribute Internet acquired personal information, including name, address or e-mail address, to outside merchants or mailing lists.

Select which branch office and then click the Submit Application button to electronically send the application to us. Use an additional email if you need to give us any further information. Please put your full name in the email.

By submitting this application you agree to the terms and conditions governing the services. A representative of Integra First Federal Credit Union will contact you to complete the Membership application. Your signature may be required as an additional condition of these services.

Security Code:

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