Mercy Credit Union -- Secure Account Application Form


	Secure Account Application Form

Applicant Information

How to join:

1. Complete the following On-Line Membership Application Request Form and submit it.
2. Membership eligibility will be confirmed and all new accounts are verified thru Chexsystems.
3. Once received, we will mail you a Membership/Signature Card for your signature and your joint owners signature (if applicable).
4. The signed Membership/Signature Card must be returned to the credit union along with an initial deposit of at least $10.00 and a copy of a government issued photo ID for all owners must be submitted for the process to be complete.

The Membership/Signature card you will sign includes the following statements and agreements:

I hereby make application for membership in Mercy Credit Union, and agree to conform to its bylaws and amendments thereof, and to subscribe for at least one (1) share. Mercy Credit Union is hereby authorized to recognize any of the signatures subscribed hereto in the payment of funds or the transaction of any business for this account. The joint owners of this account hereby agree with each other and with said Credit Union that all sums now paid in on shares, or heretofore or hereafter paid in on shares by any or all of said joint owners to their credit as such joint owners with all accumulations thereon, are and shall be owned by them jointly, with right of survivorship and be subject to the withdrawal or receipt of any of them, and payment to any of them or the survivor or survivors shall be valid and discharge said conditions of the account as established by the Credit Union from time to time. Any or all of said joint owners may pledge all or any part of the shares in this account as collateral security to a loan or loans from this Credit Union. The right, or authority of the Credit Union under this agreement shall not be changed or terminated by said owners, or any of them, except by written notice to said Credit Union which shall not affect transactions theretofore made.

Under the penalties of perjury, I certify (1) that the number shown on this form is my correct taxpayer identification number and (2) that I am not subject to backup Withholding either because I have not been notified that I am subject to back up withholding as a result of a failure to report all interest or dividends, OR THE Internal Revenue Service 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).

* Email Address:

* First Name:

* Last Name:

Drivers License #:

* Social Security #:

US Citizen:

Yes No

* Birthdate:

Marital Status:

Employer:

Joint Owner:

Joint Owner SSN:

* Street Address:
* City:	State:
* Zip #:
Current Address since:	(MM/YY)
Home Phone #:
Mobile Phone #:
Business Phone #:
I am a Mercy co-worker or affiliate:	Yes No
Employment location/department:
Related to current member:
Employee Number if Applicable:

Submit Application

Notices

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.