Membership


	MRCU is a full service financial institution located in Kansas City, Kansas that serves the residents and workers of Wyandotte, Johnson, Franklin, Miami, Jefferson, Linn, Anderson, Leavenworth and Douglas counties with offices in Kansas City, Lawrence, Overland Park and Osawatomie, Ks. In an effort to make becoming a member even easier, we've designed this Account Application that you can print, sign, and fax (913-334-9672) to our office. Your signature and an initial deposit will be required to finalize your application. You will receive account disclosures in the mail following your request to complete the account opening process.

		Account Application

			Account Type


	I/we would like to establish the following MRCU accounts or services (check all that apply):


	Share/Savings


	Share Draft/Checking


	Share Certificate/Certificate


	Money Market


	Other _________________________


	TIN Certification And Backup Withholding Information


	By signing below, I certify, in accordance with the IRS W-9 instructions provided by the Credit Union and under penalties of perjury, that the Social Security Number (SSN)/Taxpayer Identification Number (TIN) shown is my/the correct identification number and that I am NOT, unless designated below, subject to backup withholding because 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 because the IRS has notified me that I am no longer subject to backup withholding.


	I am subject to backup withholding


	Exempt


	I am not a United States citizen or resident (complete W-8 form)


	Member:


	Member Application And Ownership Information

		Account No.

Street:

City/State/Zip:

Phone Home:

Phone Work:

Employment:


	SSN/TIN:



			Driver's Lic. No.



			Date of Birth:



			Mother's Maiden Name:


	Eligibility for Membership:


	Authorization


	By signing below, I/we agree to the terms and conditions of the Membership and Account Agreement, Truth-in-Savings Rate and Fee Schedule, 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.*




	Signature Date



		Signature Date




		Signature Date



		Signature Date


	Account Services


	Payroll Deduction/Direct Deposit


	Overdraft Protection (Indicate transfer priority below)


	_______________________________________


	Other


	_________________________________


	ATM Card


	_________________________


	Debit Card


	_________________________


	Other EFT Service


	__________________


	Other


	____________________________


	Account Ownership


	Designate the ownership of the accounts and responsibility for the services requested.


	Single Party


	Joint Owner:


	Multiple Party with Survivorship


	Multiple Party without Survivorship


	SSN/TIN:


	Street:



		City/State/Zip:


		Driver's Lic. No.



		Date of Birth:


		Phone Home:



	Joint Owner:


	Phone Work:


	Mother's Maiden Name:



	SSN/TIN:


	Street:



		City/State/Zip:


		Driver's Lic. No.



		Date of Birth:


		Phone Home:


	Phone Work:


		Mother's Maiden Name:


	Account Designations


	Payable on Death (POD)/Trust Account


	Beneficiary:


	Street:



		City/State/Zip:


	All accounts


	Designate specific account(s)


	Beneficiary:


	Street:



	City/State/Zip:


	UTTMA/UGMA (as custodian for


	______________________________________(minor) under the Uniform Transfers/Gifts to Minors Act) Minor's TIN/SSN_______________________


	Agency


	Name of Agent __________________________________________________________________


	All Accounts


	Designate specific account(s)____________________________________________________


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