MidState Federal Credit Union

Online Membership Application
MidState FCU offers you the opportunity to apply for credit union membership right over the Internet. Simply provide the information requested on the form below and click on "Submit Application." We have installed the proper security measures to make sure that your application will remain confidential and well-protected during transmission. If you prefer, you may also print out the application, complete it and fax it to us at (732) 541-4449.

Application For Membership
Please check this box if you are currently a member and adding an account or changing account information. If this is the case, each person who is a holder of the new or changed account need only sign this Application and correct any applicable information.

I. INDIVIDUAL MEMBER INFORMATION
Mr. Ms. Mrs. Miss
Name (Last, First, Middle)
Birth Date		Home Telephone No.
Drivers Lic. No. / Passport No.		Social Security No. (SSN)
Present Address (Street)		City State Zip
Do you Own or Rent		County
How Long
Permanent Address		County
How Long
Employer		Position/Title
How Long		Address
Telephone No.
Member Eligibility and Identification
Mother's Maiden Name (last)
Name and Address of someone who will always know your location:

II. JOINT APPLICATION OR MINOR INFORMATION
Employer Address Position/Title Telephone No.
Name (Last, First, Middle)
Relationship to Member		Birth Date
Home Telephone No.		Drivers Lic. No. / Passport No.
Social Security No. (SSN)
Address (Street)		City State Zip
Mother's Maiden Name (last)
Employer		Position/Title
Address		Telephone No.

III. ACCOUNT TYPES
Please select the account types you want. If approved, we will open the account(s) as one of the following: (1) in the name of the Member only if section I is completed; (2) in the name of the Member and the Joint applicant as joint tenants with right of survivorship if both sections I and II are completed; or (3) in the name of the Member as custodian for the named Minor if both sections I and II are completed and the appropriate box below is checked and completed. If you are uncertain about the type of account you want or the meaning of the terms used in this section, please read ACCOUNT TYPES.

	Savings/Share Savings Account (must open first to become a member)
	Checking/Share Draft Account
	Designation of Transfer on Death Beneficiary (ies): (Name & address)
	Designation of Uniform Transfers (or Gifts) to Minors. If you check this box you hold this account "as custodian for" (name of minor) under the laws of the state in which the Credit Union is located. The minor is the owner of this account.

IV. SIGNATURES AND CERTIFICATIONS
BACKUP WITHHOLDING CERTIFICATIONS - Check either certification A or B below as applicable and write in the appropriate TIN/SSN. If you do not have a TIN/SSN, see the "Number Applied for" instructions on page 2.

TIN/SSN
	A.	By signing below, I certify under penalties of perjury that (1) the Taxpayer Identification Number (TIN) shown on this form is my correct TIN and (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding (and have written "Exempt" after my TIN on the TIN blank), 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 informed me that I am no longer subject to backup withholding. (NOTE: You must cross out Item 2 above if the IRS has notified you that you are subject to backup withholding because of underreporting of interest or dividends).
	B.	NON-RESIDENT ALIENS: By signing below, I certify under penalties of perjury that (1) I am not a United States person, or (2) if I am an individual, I am neither a citizen nor a resident of the United States.

By signing below, the undersigned apply for membership in this Credit Union; agree to its by-laws and the terms and conditions of any approved account, as amended from time to time; and authorize the Credit Union to verify credit and employment history by any necessary means, including preparation of a credit report by a credit reporting agency. The undersigned certify that information provided on this Application is true and correct and that the terms on the Application apply to all accounts held by the undersigned at this Credit Union. By checking the boxes below, the undersigned acknowledge receipt of the named disclosures and the terms and conditions that apply to any approved account.

	Truth in Savings Disclosure
	Electronic Funds Transfer Disclosure
	Funds Availability Disclosure

THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING.

X________________________________
Applicant Signature and Date

X________________________________
Co-Applicant Signature and Date

"YOU MUST BE 18 YEARS OR OLDER TO COMPLETE THIS APPLICATION"

We will begin processing this request immediately after receiving it via e-mail or fax. A form requesting your signature will be forwarded to you soon to complete the application process. Thank you.

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