Secure Membership Application Sign Up Form
83 Merrimack Street, Lowell, MA 01852
Phone: (978) 328-5100 • Fax: (978) 458-8933

Instructions: Sections 1, 2, and 5 must be completed. Please review entire application and complete additional sections as applicable. $25.00 is the minimum required to establish membership and open your account.
1. YOUR INFORMATION
PRIMARY OWNER/MEMBER
First Name:
Middle Name or Initial:
Last Name:
Social Security #:
Birthdate (MM/DD/YY):
     Male Female
Street Address:
City:
State:
Zip:
# years at this address
Home Phone #:
Cell Phone #:
Work Phone #: Ext:
Email Address:

Name & address of nearest relative not living with you:
Name (first and Last):
Street Address:
city/st/zip:

JOINT OWNER
First Name:
Middle Name or Initial:
Last Name:
Social Security #:
Birthdate (MM/DD/YY):
     Male Female
Street Address:
City:
State:
Zip:
# years at this address
Home Phone #:
Cell Phone #:
Work Phone #: Ext:
Email Address:
2. FIELD OF MEMBERSHIP
I am eligible to join through my Employer:
Name: Address:
I am eligible to join as a member of:
Organization Name:
I am eligible to join because I live, work, worship, or attend school located in the City of Lowell Massachusetts.
Name of Company/Church/School:
I am eligible to join through the following immediate family member:
Person's Name: Member Number:
This person is my:
spouse/domestic partner, child, grandchild, parent, grandparent, or sibling
3. ACCOUNTS & SERVICES
Instructions: I/we will check the boxes below for the services I/we are applying for.
    x   Primary Share Savings ($25 required to open and maintain Membership)
    x   Personal Identification Number (PIN) for Electronic Service usage. (A PIN will be generated and mailed to the Primary Owner’s address.)
    x   Electronic Accessibility via PC Branch and Easy Touch Telephone Teller
    x   e-Statements: receive monthly statements online using PC Banking
Free Checking Account. Print the following on my checks:
    Primary Name Joint Name Address Phone

On Line Bill Pay Services: I would like to pay my monthly bills using online Bill Pay Services.

Master Money® Debit Card* (also serves as your ATM card) or ATM Card (for members between ages 12-17)

Information on Certificate of Deposit Requested:

    Term     Rate     Yield
    Dividend Checks? Yes No
4. CONSUMER LOANS

I/We am/are NOT interested in loan at this time. If checked, skip remaining and complete Section 5 below.
I/We am/are interested in applying for the loan(s) indicated below. I understand that this is not a loan application. This is a request for additional information.
Check if you believe this will be joint credit
Monthly Gross Income of Primary Member $
Monthly Gross Income of Joint Owner $
Housing Expenses: My monthly (mortgage) (rent) is $.
I/We are interested in the following loan types:
Automobile. Anticipated amount of loan $.
Personal Unsecured Loan. Anticipated amount of loan $.
Overdraft Line of Credit associated with my checking account. Anticipated amount of line of credit $.

5. AGREEMENT AND TAXPAYER ID NUMBER (TIN) CERTIFICATION & BACKUP WITHHOLDING
ADDITIONAL ACCOUNTS: Account Owner(s) agree that this account opening form may be used on any and all additional accounts established with the same owners unless otherwise requested.

TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION
Under penalties of perjury, I certify that (1) the Social Security Number (SSN)/Taxpayer Identification Number (TIN) shown is my correct taxpayer identification number, (2) I am not subject to back-up withholdings because: (a) I am exempt from backup withholdings, or (b) 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 dividends, or (c) the IRS has not notified me that I an no longer subject to backup withholding, AND (3) I am a U.S. Person (including a U.S. resident alien). INSTRUCTIONS: Cross out #2 above if the IRS has notified that you are subject to backup withholdings for failure to report all interest and dividends in your tax return.

AUTHORIZATION
I/we certify that I/we am/are within the field of membership, whether by way of employment, by association, or an immediate family relationship. I/We with my signature hereby agree to the Credit Union’s By-Laws, and Rules and Regulations, and any amendments thereto. If an ATM/Debit card or EFT service is requested and provided, I/We agree to the terms and acknowledge receipt of the EFT Agreement. I/We authorize the Credit Union to verify the information provided and to obtain consumer reports from consumer reporting agencies or others in connection with this account. I also agree to the terms and conditions of the Account Agreement and have received a copy of the Truth-in-Savings Agreement including Electronic Funds Transfers, Funds Availability Policy, Privacy Disclosure and Fee Schedule. The Internal Revenue Service does not require your consent to any provision of this document other than the certification to avoid backup withholding.


  By submitting this request, By checking this box I acknowledge that I have read and agree to the terms of this Online Disclosure.