Boulder Valley Credit Union Membership / New Accounts Application
IMPORTANT INFORMATION ABOUT PROCEDURES FOR ESTABLISHING MEMBERSHIP/NEW ACCOUNTS.
To assist the government fight the funding of terrorism and money laundering activities, the USA PATRIOT ACT requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. When you open an account, we will ask for your name, address, date of birth, SSN, and other information that will allow us to identify you. Boulder Valley Credit Union will maintain the confidentiality of any information obtained in accordance with Boulder Valley Credit Union's privacy policy and applicable laws and regulations. BVCU reserves the right to request additional information to support your identity at any time during the membership application process in order to comply with the USA PATRIOT ACT.

PLEASE NOTE: Required fields are marked with an asterisk(*). This form is SECURE in that it will only be printed locally by your PC and will NOT be transmitted electronically.

Membership Application and Ownership Information

Member/Owner Name *
(Last, First Middle)

Social Security Number
(SSN) or TIN *

Date of Birth *

Driver's License * Number | State:

Date Issued | Expiration Date:


Trade Name, Trust Name, Estate Name, or Club Name (if applicable):
Physical Address *

City | State | Zip Code:
 Mailing Address (if different from Physical Address)

City | State | Zip Code:
Phone Numbers
Home: Work: Cell:
Home Phone Number: Listed Unlisted
Personal E-mail Address *
Existing Member Number
(to add accounts/services to an existing membership)
Employment *


Eligibility for Membership *
(In almost all cases we can qualify you for membership,
choose "Other" if the other choices do not apply)
Employer:
Friends/Family
Other

Password (Mother's Maiden Name):

Account Type

All of the terms, conditions, form of account ownership, account selection and other information indicated on this card apply to all of the accounts listed below unless the credit union is notified in writing of a change.
Accounts Requested
Savings
Checking
Debit Card   NOTE: By checking this box you also
acknowledge acceptance of the Debit Card Agreement
Share Certificate Account
Money Market Account
Club / Organizational Account
Other:

Preferred Branch (if applicable):
Arapahoe
Broadway
Louisville
Estes Park
Are you in the market to:
Purchase / Refinance a Home
Purchase a New or Used Auto
Take Out / Refinance a Second Mortgage
Receive Financial Planning
Other, please specify:

Account Services

All of the following account services are FREE with your membership upon approval by a Member Service Representative.
Payroll Deduction / Direct Deposit
Overdraft Protection
ATM Card
Internet Banking
Online BillPay
E-Statements
TellerPhone (Audio Response)
Other:

 

Account Ownership

Designate the ownership of the accounts and responsibility for the services requested:
Individual Joint Account with Survivorship Joint Account Without Survivorship

Joint Owner Name (Last, First Middle)

Physical Address

City | State | Zip Code:

Home Phone:
Home Phone Number: Listed Unlisted
Work Phone:

Social Security Number (SSN) or TIN:

Driver's License Number | State:

Date of Birth:

Personal E-mail Address

Password (Mother's Maiden Name):
 Joint Owner Name (Last, First Middle)

Physical Address

City | State | Zip Code:

Home Phone:
Home Phone Number: Listed Unlisted
Work Phone:

Social Security Number (SSN) or TIN:

Driver's License Number | State:

Date of Birth:

Personal E-mail Address

Password (Mother's Maiden Name):
Parties listed herein will be deemed joint owners unless otherwise specified

Account Designations

Payable on Death (POD) / Trust Account
Beneficiary / POD Payee:
Address:
City / State / ZIP:

Beneficiary / POD Payee:
Address:
City / State / ZIP:

Agency
    Print Name of Agent:

Signature: _______________________________    Date:

UTTMA/UGMA
    (as custodian for: (minor)
under the Uniform Transfers/Gifts to Minors Act) Minors TIN/SSN:

Other:

TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION

Under penalties of perjury, I certify that:
(1) The number shown on this form is my correct taxpayer identification number,
(2) 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 (IRS) that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS 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).

Certification Instructions. Cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. Cross out item 3 and complete a W-8 BEN if you are not a U.S. person

Check this box if you are subject to backup withholding.

Authorization

By signing below, I/we agree to the terms and conditions of the Membership and Account Agreement, Truth-in-Savings Disclosure, 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 Disclosures applicable to the accounts and services requested herein. If an access 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 Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

FOR CREDIT UNION USE ONLY

See Account Change Card   See Insurance Beneficiary Card
Date of Membership  Opend/App'd By Member Verification

Credit Report
Check Verify
PIN Request
Access Card
Audio Response
PC Access/Internet Banking