Membership Enrollment Form

582 S. Round Barn Road. P.O. Box 817
Richmond, IN 47375
Phone: (765) 962-2561 • Fax: (765) 966-3989

How To Join

Complete the following online membership application request form and submit it.
Once received, we will contact you to schedule a time to have you come in or mail to you a pre-filled application form requiring your signature and the signature(s) of your joint owner(s) (if applicable).
The signed membership application must be obtained by the credit union along with an initial deposit of at least $5.00 and the $0.25 membership fee and/or a direct deposit form, and a copy of a government issued photo ID for the application process to be completed.

IMPORTANT INFORMATION ABOUT PROCEDURES
FOR OPENING A NEW ACCOUNT

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

We ask for your understanding as we work to support these efforts to maintain the security of your funds and our country.

Under penalties of perjury, I certify that:

The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued), and
I am not subject to backup withholdings 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 a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholdings, and
I am a U.S. citizen or other U.S. person. For federal tax purposes, you are considered a U.S. person if you are: an individual with is a U.S. citizen or U.S. resident alien; a partnership, corporation, company, or association created or organized in the United States or under the laws of the United States; an estate (0ther than a foreign estate); or domestic trust (as defined in Regulations section 301.7701-7).
The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting correct.

Certification Instructions.
Check here 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. Complete a W-8 BEN if you are not a U.S. person. If a W-8 BEN is completed, your signature does not serve to certify this section.

Applicant Information

First Name:	MI:	Physical Address :
Last Name:		City :	State:
Date of Birth:		Zip :
Mother's Maiden Name:		Mailing Address :
Social Security #:		City :	State:
Driver’s License # :		Zip :
Driver License Issue Date :		Home Phone :
Driver License Expiration Date :		Business Phone :
Driver License State of Issue :		Employer:
Email Address :		Occupation / Title:

Will this be a joint account? Yes If yes, joint owner’s name: No
Please choose a Branch : Please select the County in which you live:

Joint Applicant Information

Joint Applicant's First Name:	MI:	Physical Address :
Joint Applicant's Last Name:		City :	State:
Date of Birth:		Zip :
Mother's Maiden Name:		Mailing Address :
Social Security #:		City :	State:
Driver’s License # :		Zip :
Driver License Issue Date :		Home Phone :
Driver License Expiration Date :		Business Phone :
Driver License State of Issue :		Employer:
Email Address :		Occupation / Title:

Additional Services

Free Checking
Kasasa Cash Checking
Debit Card
Kasasa Saver

Special Savings
Vacation Club
Christmas Club
Loans

Beneficiary(s)

Name	Social Security	Relationship

How did you hear about us?

Web Site
Television
Newspaper
Movie theater

Search engine
Friend / Family - Name:
Member/Co-Worker - Name:
Other:

Submit Application

Natco Credit Union reserves the right to use the above information to obtain verifications of identity and background before opening any accounts. We may also access information about you from a consumer reporting agency, such as a copy of your credit report, before opening any account. By submitting this form, I/we grant full permission to do so.

To avoid delays in processing your request please provide us with the best method and time to contact. Best method of contact:
Home Phone Mobile Phone Work Phone What time of day is best to call:

Date:	Primary Signature:	Joint Signature:
Enter The Security Code Displayed In The Box Below: [858932]

Membership Terms & Conditions I have read and agree to NatcoCU’s Terms and Conditions
eSignature Disclosure I have read and agree to NatcoCU’s eSignature Dislcosure

NCUA