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Intern Number
FOR INTERNAL USE ONLY Account Number ______________________________________ Teller Number __________________ Date __________________
©PSECU Form # 2062 11/12
PSECU MEMBERSHIP APPLICATION
Millersville University
Complete application with ball point pen. For non-U.S. citizens, in addition to the ID documents, please provide copies of your documentation of citizenship
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Security card and/or W-8BEN). For current rates, fees and the Truth in Savings Account Disclosures, visit psecu.com/rates or call 800.237.7328.
APPLICANT ELIGIBILITY
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I AM A STUDENT – 3022
I AM A FAMILY MEMBER – 3025
My grade level is __ Freshman __ Sophomore __ Junior __ Senior
and my anticipated graduation date will be ________________________________________________
I AM A FACULTY/STAFF MEMBER – 3026
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APPLICANT INFORMATION
JOINT OWNER
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_____________________________________________________________________________
SOCIAL SECURITY # OR TAX ID # (If you’re under 18, please also provide a copy of your Social Security Card.)
_____________________________________________________________________________
FIRST NAME, MIDDLE INITIAL, LAST NAME, SUFFIX
_____________________________________________________________________________
E-MAIL ADDRESS
_____________________________________________________________________________
HOME PHONE NUMBER
_____________________________________________________________________________
WORK PHONE NUMBER
_____________________________________________________________________________
CELL PHONE NUMBER
PREFERRED METHOD OF CONTACT ___ E-mail ___ Home ___ Work ___ Cell
DATE OF BIRTH: _______/_______/_______
RELATIONSHIP TO APPLICANT (OWNER) BBB$GXOW)DPLO\0HPEHUBBB&KLOG6WHS&KLOG
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_____________________________________________________________________________
SOCIAL SECURITY # OR TAX ID # (If you’re under 18, please also provide a copy of your Social Security Card.)
_____________________________________________________________________________
FIRST NAME, MIDDLE INITIAL, LAST NAME, SUFFIX
_____________________________________________________________________________
E-MAIL ADDRESS
_____________________________________________________________________________
HOME PHONE NUMBER
_____________________________________________________________________________
WORK PHONE NUMBER
PLEASE SELECT ONE BOX BELOW:
I am a U.S. citizen.
I am a permanent resident alien.
I am not a U.S. citizen or permanent resident alien.
_____________________________________________________________________________
CELL PHONE NUMBER
PREFERRED METHOD OF CONTACT ___ E-mail ___ Home ___ Work ___ Cell
DATE OF BIRTH: _______/_______/_______
_____________________________________________________________________________
PROFESSION/JOB TITLE NUMBER 6HHSDJHWRÀQGWKH3URIHVVLRQ-RE7LWOH1XPEHUWKDWEHVW
describes your occupation.)
__________________________________________________________________________
DRIVER’S LICENSE # OR GOVERNMENT-ISSUED ID # (If you do not have a driver’s license or
PLEASE SELECT ONE BOX BELOW:
I am a U.S. citizen.
I am a permanent resident alien.
I am not a U.S. citizen or permanent resident alien.
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_______________________
STATE
_______/_______/_______
ISSUE DATE
_______/_______/_______
EXPIRATION DATE
____________________________________________________________________________
PERMANENT STREET ADDRESS ,IDGGUHVVLVD3RVW2IÀFH%R[DOVROLVWWKHSODFHRIUHVLGHQFH
_____________________________________________________________________________
PROFESSION/JOB TITLE NUMBER 6HHSDJHWRÀQGWKH3URIHVVLRQ-RE7LWOH1XPEHUWKDWEHVW
describes your occupation.)
_____________________________________________________________________________
DRIVER’S LICENSE # OR GOVERNMENT-ISSUED ID # (If you do not have a driver’s license or
___________________________________________________________________________
CITY, STATE, ZIP
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OCCUPANCY STATUS BB%X\LQJ2ZQZLWK0RUWJDJHBB*RYHUQPHQW4XDUWHUV
STATE
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HOW LONG AT THIS ADDRESS? _______________________
If less than 2 years, list previous address ______________________________________________
_____________________________________________________________________________
_______________________
_______/_______/_______
ISSUE DATE
_______/_______/_______
EXPIRATION DATE
_____________________________________________________________________________
PERMANENT STREET ADDRESS ,IDGGUHVVLVD3RVW2IÀFH%R[DOVROLVWWKHSODFHRIUHVLGHQFH
_____________________________________________________________________________
CITY, STATE, ZIP
OCCUPANCY STATUS BB%X\LQJ2ZQZLWK0RUWJDJHBB*RYHUQPHQW4XDUWHUV
ARE YOU A POLITICALLY EXPOSED PERSON (PEP)?
__ Yes __ No
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ARE YOU A CLOSE ASSOCIATE OR FAMILY MEMBER OF A PEP? __ Yes __ No
DO YOU ALSO LIVE IN A FOREIGN COUNTRY? __ Yes __ No
EMPLOYMENT STATUS: BB(PSOR\HGBB8QHPSOR\HGBB5HWLUHGBB+RPHPDNHU
__ Student __ Minor __ Disabled
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HOW LONG AT THIS ADDRESS? _______________________
If less than 2 years, list previous address ______________________________________________
_____________________________________________________________________________
ARE YOU A POLITICALLY EXPOSED PERSON (PEP)?
__ Yes __ No
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ARE YOU A CLOSE ASSOCIATE OR FAMILY MEMBER OF A PEP? __ Yes __ No
DO YOU ALSO LIVE IN A FOREIGN COUNTRY? __ Yes __ No
EMPLOYMENT STATUS: BB(PSOR\HGBB8QHPSOR\HGBB5HWLUHGBB+RPHPDNHU
__ Student __ Minor __ Disabled
COMPLETE YOUR PIN/PASSWORD DO NOT DETACH
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use symbols, numbers between 0000 and 0009, repeating numbers (1111, 2222, etc.), or consecutive ascending or descending numbers (1234, 4321, for example). Please select different PINs and write them
in the spaces below. Please note them for your reference. 36(&8GRHVQRWNHHS\RXU3,1VRQÀOH You will need your PSECU Member Account PIN when contacting us.
YOUR MEMBER ACCOUNT PIN:
YOUR CHECK CARD/ATM PIN:
ONLINE BANKING PASSWORD:
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P. O. B OX 6 7 0 1 3 , H A R R I S B U R G, PA 1 7 1 0 6 - 7 0 1 3
800.237.7328
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CHECK CARD
CHECKING
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Your checking will automatically overdraft from Regular Shares (S1). The basic-style checks you receive are
free. Your name and address will appear on your checks. Please allow two weeks to receive your checks.
___ Add my home phone number
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___ 1 Check Card in my name
___ 2 Check Cards in my name
___ 2 Check Cards, 1 in my name and 1 in my joint owner’s name
___ Add my joint owner’s name
ONLINE BANKING
Your Check Card will automatically overdraft from Regular Shares (S1). However, overdrafting will not
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(S4) for your purchase to be authorized. Overdrafting will apply at the time your purchase is presented
to PSECU for payment. Please allow two weeks to receive your Check Card.
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SIGNATURES
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I/We apply for membership in PSECU and agree to the conditions stated on this application and in the Agreements & Disclosures and the Bylaws, rules and regulations of PSECU which will be provided to me/us as
required by law. I/We apply for and agree to the stated terms for each service requested on this application. From time to time, PSECU will announce additional services. My/Our use of these services will indicate
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reports, concerning me/our or my/our affairs and all joint owners upon request of this credit union. I/We understand that I/we and any or all of my/our joint owners have the right to request in writing, the nature
and scope of the credit union’s investigation. Any negative balance created in this account shall bear interest at the highest unsecured loan rate offered by PSECU until paid in full. Repayment of this amount will be
the personal obligation of all joint owners of any account owned by those individuals. I/We understand that it is a federal crime to willfully or negligently provide incomplete or incorrect information on requests made
to State Chartered Credit Unions insured by the National Credit Union Administration. I/We understand that PSECU will rely on all the information in this membership application to ensure membership eligibility.
I/We certify under penalty Title 18, United States Code, Section 1001, et seq. that the information on this application is true and correct. 7KH,QWHUQDO5HYHQXH6HUYLFHGRHVQRWUHTXLUH\RXUFRQVHQWWRDQ\
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_________________________________________________
_________________________________________________
___________/___________/___________
APPLICANT’S SIGNATURE 3OHDVHVLJQLQLQN
PRINT SIGNATURE
DATE
_________________________________________________
_________________________________________________
___________/___________/___________
JOINT OWNER’S SIGNATURE 3OHDVHVLJQLQLQN
PRINT SIGNATURE
DATE
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year of membership, the initial $5 share will be retained by PSECU. In order to retain membership in the credit union, members must maintain a $5 share in the credit union. If you are sending additional funds, please
indicate how you wish your money to be distributed. Send application and your check, if needed to 36(&8$WWQ$SSOLFDWLRQ3URFHVVLQJ'HSW32%R[+DUULVEXUJ3$
$ _____________ 5(*8/$56+$5(66 _____________ CHECKING/TRANSACTIONAL SHARES (S4)
PROMOTIONAL CODE _____________ REFERRAL CODE _____________
W-9 FORM - INTERNAL REVENUE SERVICE
TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION
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If you are a foreign person (not a U.S. citizen or resident), please print, complete and return form W-8BEN to us with any required documents.
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manner not permitted by law may cause that service or related services to be terminated at PSECU’s discretion. You further agree, should illegal use occur, to waive any right to
sue PSECU for such illegal use or any activity directly or indirectly related to it. Additionally, you agree to indemnify and hold PSECU harmless from any suits or other legal action
or liability, directly or indirectly, resulting from such illegal use. 36(&8UHVHUYHVWKHULJKWWRGHFOLQHDQ\WUDQVDFWLRQWKDWZHFRQVLGHUIUDXGXOHQWVXVSLFLRXVRULOOHJDO36(&8
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USA PATRIOT ACT
IDENTITY VERIFICATION NOTICE
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Number) and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying document(s). The law requires us to maintain
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The expression “politically exposed person” (“PEP”) applies to persons, their families, and close associates who perform important public functions for a foreign country, which
would include a Senior Foreign Political Figure.
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THIS CREDIT UNION IS FEDERALLY INSURED BY THE NATIONAL CREDIT UNION ADMINISTRATION. EQUAL OPPORTUNITY LENDER.
© PSECU 12-UNGNAD-0904