Membership Application


A. Account Information
Are you currently living or working in Pinellas County, Pasco, or Hernando Counties? Yes No Are you a family member of a current Achieva member? Yes No If you answered "yes" to either question, you're eligible for membership.
New Account Individual Account(s) [Complete Sections B, D, E] Joint Account(s) [Complete Sections B, C, D, E]		Replacement Card* Account Number Joint Owner Change: Add Delete Replace Existing Beneficiary Change: Add Delete Replace Existing Name Change: Previous Last Name *This change supercedes all previous designations. Complete fields below to provide details of this change. Additional documentation may be required to complete this request.

Name:

SSN:

(555-55-5555)

Address:

City:

State:

Zip:

Employer:

Email Address:

Home Phone:

(727-555-5555)

Work Phone:

(727-555-5555)

Date of Birth*:

(mm/dd/yyyy)

Drivers License #:

Are you a U.S. Citizen or Resident Alien?

Yes No Not sure

*Note: You must be 18 years or older in order to open an account.

C. Joint Owner Enrollment Information

Joint Owner 1

Name:

SSN:

(555-55-5555)

Home Phone:

(727-555-5555)

Date of Birth:

(mm/dd/yyyy)

Work Phone:

(727-555-5555)

Driver's License #:

Joint Owner 2

Name:

SSN:

(555-55-5555)

Home Phone:

(727-555-5555)

Date of Birth:

(mm/dd/yyyy)

Work Phone:

(727-555-5555)

Driver's License #:

By checking below, I hereby apply for membership in the Achieva Credit Union, and under this enrollment application, I authorize the Credit Union to establish savings, checking, money market, certificate of deposit and other share accounts for my use. I request that I be given access to my accounts by telephone audio response, ATM, debit card/or any other electronic device which I may qualify now or in the future. I acknowledge receiving a copy of the credit union brochure(s) that explains the terms and conditions of my accounts and includes the disclosures for Electronic Fund Transfers, Funds Availability, Truth-in-Savings, and Rate and Fee Schedules. I agree to the terms and conditions for each account and service that I use, and I understand this application form will govern the ownership for all accounts established under this membership number unless other ownership is specifically stated in writing on forms acceptable to the credit union. I understand that on Joint Accounts, if I wish to list any beneficiaries, that all account owners must be deceased before funds can be allocated to any beneficiaries listed on this account. I authorize the credit union to verify my employment, my credit and any other banking history. I understand the credit union will request information from me to verify my identity in accordance with the USA Patriot Act.

Under penalties of perjury, I certify that the number shown on this form is my correct taxpayer identification number and that 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 that I am subject to backup withholding as a result of a failure to report all interest of dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding.

I agree with the above statement:

New Member		Joint Owner
I Agree		I Agree

E. Pay on Death Acccount

Beneficiary 1

Name:

Date of Birth:

(mm/dd/yyyy)

Address:

SSN:

(555-55-5555)

Beneficiary 2

Name:

Date of Birth:

(mm/dd/yyyy)

Address:

SSN:

(555-55-5555)

I waive my right to include a beneficiary on this account.

F. I am interested in the following products and services: (please check all that apply)

Savings
Money Market
Certificate of Deposit
Checking
Visa^® or MasterCard^®
Debit MasterCard^®

Consumer Loans
First Mortgage
Home Equity Loans
Individual Retirement Accounts (IRAs)
Direct Deposit