7/31/2019 Form Membership App

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Other (describe):

 _____________________________________________________________________________________________________________________________________________Taxpayer ID / Social Security Number

Applicant Requests All Electronic Services Available,Except Those Checked Below

_____________________________________________________________________________________________ 

Membership Application

Primary Member (PLEASE PRINT - All items must be completed)

 _________________________________________________________________________________________________________________________________________________________________

Last Name First Name Middle Name

 _________________________________________________________________________________________________________________________________________________________________

Current Address City State ZIP

Photo ID Type

/ / ( ) ( )  _____________________________________________________________________________________________________________________________________________Birth date (mm/dd/yy)  City of Birth Mother's Maiden Name Residence Telephone Business Telephone/Ext.

 ______________________________________________________________________

Renter

Joint Owner if Desired for Share Accounts (PLEASE PRINT - All items must be completed) 

Membership Eligibility (SELECT ONE OF THE FOUR - All items in your selection must be completed) 

3.1. 2.

Employment at: (Company Name)  Contract Employee of: (Company Name) 

4. _______________________________________________________________________________________________________________________________________________________________

Family Member of: (Primary Member Name)  Relationship to Member Family Member's KeyPoint Credit Union Account Number

Accounts (SELECT ALL THAT APPLY)

Savings

Money Market

Loan Account Only(Separate application required)

E-mail Address

USA PATRIOT ACT NOTICE: To help the government fight funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify anrecord information that identifies each person who opens an account. When you open an account, we will ask for your name, address, date of birth and other information that wallow us to identify you. We may also ask to see your driver's license and other identifying documents .

 _________________________________________________________________________________________________________________________________________________________________

Mailing Address City State ZIP Issue State / County

 _________________________________________________________________________________________________________________________________________________________________

Employer Name City State ZIP Issue Date

2nd ID Type

Expiration Dat

Work E-mail AddressAre you a senior foreign political figure or a close associate of a senior foreignpolitical figure?

Is foreign wire activity anticipated on accounts to be established under thismembership? Homeowner

YES NO

Checking

IRA

I do not want to enroll in Access 365 (automated telephone access)

I do not want to enroll in Online Banking (including Bill Payment)

I do not want an ATM Card to access my savings account.

I do not want a VISA Debit Card to access my checking account.

Live/Work/Worship/Attend

/ /

/ / / /

Traditional

For your convenience and to help conserve environmental resources, your accountwill be automatically set-up to receive eStatements that can be accessed anytimethrough Online Banking.

No thank you, I prefer to receive paper statements in the mail.

Certificates:

Individual Retirement Accounts

Term

Occupation

You are: a U.S. Citizena Lawful Permanent U.S.Resident

Other (describe):

ID Number

/ /

Expiration Dat

(County)

R

(W9 required for foreign status)

 _________________________________________________________________________________________________________________________________________________________________

Last Name First Name Middle Name

 _________________________________________________________________________________________________________________________________________________________________

Current Address City State ZIP

Photo ID Type

/ / ( ) ( )  ________________________________________________________________________________________________________________________________________________________________ 

Birth date (mm/dd/yy)  City of Birth Mother's Maiden Name Residence Telephone Business Telephone/Ext.

 _____________________________________________________________________E-mail Address

 _________________________________________________________________________________________________________________________________________________________________

Mailing Address City State ZIP Issue State / County

City State ZIP Issue Date

2nd ID Type

Expiration Dat

Work E-mail AddressIs joint owner a senior foreign political figure or a close associateof a senior foreign political figure?

Is foreign wire activity anticipated on accounts to be established

under this membership?

YES NO

/ /

/ / / /

Occupation

You are: a U.S. Citizena Lawful Permanent U.S.Resident

ID Number

/ /

Expiration Dat(W9 required for foreign status)

 ___________________________________ 

Relationship to Primary Member

Term

 ____________________________________________________________________________________ ______________________________________  _______________ __________

Employer Name

 _________________________________________________________________________________________________________________________________________________________________

Taxpayer ID / Social Security Number

2805 Bowers AvenueSanta Clara, CA 95051FAX - 408-731-4485

Other

Cell Phone

( ) 

 ________________________________

( )  _______________________________

Cell Phone

Health Savings Account (HSA)

7/31/2019 Form Membership App

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First Overdraft Account Number _____________________________________________ Second Overdraft Account Number  ______________________________________________________

INSTRUCTIONS: Indicate the account number of the account(s) you wish to debit in the event of an overdraft. (Line of credit transfers are made in $50 increments; If an overdoption is not selected, checks may automatically be returned). Overdrafts are to be covered by transferring funds from:

 __________________________________________________________________________ _______________________________________________________________________________Primary Member Signature Date Joint Member Signature Date

OFFICE USE ONLY

Membership Account Number: _______________________________________________  New WaivedDate: _____/______/______ Staff Initials: ____________

mm dd yy Revised Signature Card: (check all that apply) Name Change Adding Joint Other _______________

 __________________________________________________________________________ __________________________________________________________________________________ 

Account Opened by (First & Last Name) / Cash Box Number   Chexsystems Manager/Supervisor Approval (I certify that I have checked all of the above information)

(REV. 07/11

Checking Overdraft Protection (Complete only if Checking is selected)

INSTRUCTIONS: If this is a joint account, in the event of the death of one of the joint owners, the other joint owner retains full ownership of all funds in the account. If this is aindividual account, then upon the death of the individual owner, funds in the accounts covered by this application will be payable to the individuals named below. If no percentagare shown, distribution will default to equal division. If no beneficiaries are named, funds pass at death to the estate of the last surviving owner.

 _______________________________________________________________________________________________________________________________________________________ Name (First & Last)  Address (Street, City, State, ZIP)

1. The person identified as "MEMBER," if not already a KeyPoint member, applies for membership and certifies under penalty of perjury that the membership eligibility statement isaccurately completed.

2. I agree to abide by applicable law and KeyPoint Credit Union's bylaws in all dealings with KeyPoint Credit Union.

3. You are authorized to check my credit and account history, including verification of information on this application.

4. This application constitutes my request for the services indicated on this application and my continuing authorization to open accounts for me under my KeyPoint membership uponmy oral or written request and deposit of funds.

5. If a joint owner is indicated, all accounts established under this membership other than IRA will be joint ownership with right of survivorship. Joint owners are equally responsible withmembers, jointly and individually, for complying with all terms of all agreements with KeyPoint Credit Union.

6. I acknowledge receipt of the KeyPoint Member Handbook, the Truth in Savings Disclosure applicable to any accounts I have opened, and FeeSchedule and consent to their terms as amended from time to time by proper legal notice to me.

7. I agree that if I become indebted to KeyPoint Credit Union in any way, including by use of plastic cards or by overdrawing my checking account, if I do not pay what I owe according tomy agreements, you can take any funds voluntarily deposited to KeyPoint share accounts in which I have an interest to recover all or part of what of I what I owe without notice and without waiving other collection rights. This consent applies to all voluntarily deposited funds, including funds that may otherwise be exempt from creditors remedies, such as social security direct deposit, unless prohibited by law or the share agreement. This consent is in addition to any right of the Credit Union to impress a lien on my shares under CaliforniaFinancial Code Sec. 14856 or any equitable right of offset.

8. Substitute W-9 Taxpayer ID Certification: You may request official IRS W-9 instructions from a KeyPoint staff member or, if applying online, click here to obtain instructions athttp://www.irs.gov/pub/irs-pdf/fw9.pdf.I declare under penalty of perjury that (a) I am a U.S. Person (including resident alien), (b) the taxpayer ID number provided onthis application is correct and (c) either (1) I have never been notified by the IRS that I am subject to backup withholding due to failure to report dividends orinterest or (2) I have been notified by the IRS that I am no longer subject to backup withholding. The IRS does not require my consent to any term of any agreementwith the Credit Union other than the certifications required to avoid backup withholding. If I am subject to backup withholding, the following box is checked.

%

 Address (Street, City, State, ZIP)%

Pay-On-Death (PLEASE PRINT)

 _______________________________________________________________________________________________________________________________________________________  

Name (First & Last)

Membership Application and AgreementBy signing this application and submitting it to KeyPoint Credit Union, or by submitting this application to KeyPoint electronically:

INSTRUCTIONS: By completing this application, I request membership in KeyPoint Credit Union. I agree to abide by the laws and bylaws in all dealings with KeyPoint Credit Union. Theinformation that I have stated on the application is true and complete. You are authorized to check my credit history, including verification of information on this application. I acknowledgereceipt of and agree that all of my KeyPoint Credit Union accounts will be subject to the KeyPoint Credit Union Master Disclosure/Truth-in-Savings Disclosure and Fee Disclosure as amendedfrom time to time. By signing below, I certify under penalty of perjury that the Taxpayer ID/Social Security number provided on this application is correct and that I am notsubject to backup withholding due to underreporting of dividends or interest. I also certify that I am a U.S. person (includes a U.S. resident alien). The IRS does notrequire my consent to any provisions of the application other than the certification to avoid backup withholding.

Promo Code: _____________

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