NRFCU - Membership and Account Card Application

		Membership and Account Card

Full Name
Social Security #	Date of Birth
Address	Apt#
City		State Zip
Home Phone#	Work Phone# Ext.
Employer
Driver's License #	ID Card # State Expiration Date
Email
Mother's Maiden Name

Eligibility for Membership: (Choose One)

Community Area
Address for Affiliation	Portland, OR
Employer (please list)
Family Member's Name	Relationship:

Joint Member Information (if applicable)
Full Name
Social Security #		Date of Birth
Address	Apt#
City		State Zip
Home Phone#		Work Phone#
Employer
Driver's License #	ID Card # State Expiration Date
Email
Mother's Maiden Name

Second Joint Member Information (if applicable)

Full Name
Social Security #		Date of Birth
Address	Apt#
City		State Zip
Home Phone#		Work Phone#
Employer
Driver's License #	ID Card # State Expiration Date
Email
Mother's Maiden Name

I/We would like to apply for the following Northwest Resource FCU accounts or services (check all that apply):

Regular Savings (required $5.00 minimum balance)
Online Banking (Password) (4-20 characters or #s)
Call Connection (Telephone Banking Password) (Must be 4 digits)
Premium Checking ($25.00 minimum opening balance) - Debit Card PIN# (4 digits)
Value Checking ($25.00 minimum opening balance) - ATM Card PIN# (4 digits)
Money Market Savings Account ($2,500 minimum balance)
Certificate Account ($500 minimum balance) Term: Amount:
Other, Please Specify

Beneficiaries: (complete only if Payable on Death Account)

Check this box if you would like to name a beneficiary(ies) on your account.

Beneficiary 1
Address		Birth Date
City/ST/Zip		SSN

Beneficiary 2
Address		Birth Date
City/ST/Zip		SSN

TIN Certification and Backup Withholding Information

By signing this card, I certify, under penalties of perjury, that (1) I am a US Person (including a US resident alien), (2) the Social Security number (SSN)/taxpayer identification number (TIN) shown is my/the correct identification number and (3) I am NOT, unless designated below, subject to backup withholding because I have not been notified that I am subject to backup withholding as a result of a failure to report all dividends or interest, or because the IRS has notified me that I am no longer subject to backup withholding.

Check one ONLY if it applies to you:
I am subject to backup withholding
I am not a US citizen or US person (complete W-8BEN form)
Exempt

Authorization

By signing below, I/We agree to the terms and conditions of the Membership and Account Agreement, Truth-in-Savings Rate and Fee Schedule, Funds Availability Policy Disclosure, if applicable, and to any amendment the Credit Union makes from time to time which are incorporated herein. I/We acknowledge receipt of a copy of the Agreement and Disclosure applicable to the accounts and services requested herein. If an ATM card or EFT service is requested and provided, I/We agree to the terms of and acknowledge receipt of the Electronic Funds Transfer Agreement. The Internal Revenue Services does not require your consent to any provision of this Account Card other than the certifications required to avoid backup withholding.

Member Signature_________________________________________ Date_____________

Joint Member Signature_____________________________________

If returning by mail or fax, please include photocopies (both sides) of the following required identification:
Valid Drivers License and one of the following or Valid State ID and two of the following: certified copy of birth certificate, military ID with photo, utility bill (in your name & address), health insurance card, rent receipt (in your name & address), employment ID, original Social Security Card, pay stub (current), valid passport, student ID (current year), valid credit card, alien ID card with photo.

Please print and sign this completed form and return with your opening deposit(s)
and photocopies of your required ID to:

Northwest Resource FCU • Attn: New Accounts • PO Box 2788 • Portland, OR 97208

Credit Union Use Only

Account # ___________________

Date Opened ________________

Chex Systems _______________

Date Change ________________

Member Group # __________________

Opened By _______________________

OFAC ____________________________

Changed By ______________________

Verification ________________

ID Type ___________________