Secure Account Application Form

12510 W 62nd Terr., Suite 104, Shawnee KS 66216
Phone: 913-588-5376 | Fax: (913) 588-5383

Applicant Information

How to join:

1. Complete the following On-Line Membership Applicaton Request Form and submit it.
2. Once received, and account representative will contact you to complete the membership process.

* Email Address:
* First Name:
* Last Name:
Drivers License #:
* Social Security #:
US Citizen: Yes No
* Birthdate:
Marital Status:
Joint Owner:
Joint Owner SSN:
* Street Address:
* City: State:
* Zip #:
Current Address since: (MM/YY)
Home Phone #:
Mobile Phone #:
Business Phone #:
I currently work at KUMC Medical Center: Yes No
Employment location/department:
Related to current member:
Submit Application


I/we certify that this information on all pages had been supplied truthfully, accurately and voluntarily, and therefore authorize this credit union to investigate our creditworthiness, credit history and financial responsibility through any credit bureau or by any other reasonable means for consideration.


Copyright 2017 KUMC Credit Union