| APPLICATION
FOR MEMBERSHIP |
Account #
_______________________________
Initial Amt. $ ____________________________
Approved
(date)
(by) |
[ ] Check
here to order our basic style checks.
If mailing your application include a
copy of your driver's license and your initial deposit. |
|
|
______________________________________
I. INDIVIDUAL MEMBER INFORMATION ________________________________________ |
|
Name (Last, First,
Middle)
|
Date |
[
] Mr. [ ] Ms.
[ ] Mrs. [ ]
Miss |
|
Birth
Date
|
Home
Telephone No.
|
Drivers
Lic. No / Passport No.
|
Social
Security No. (SSN)
|
|
Address
(Street, City, State & Zip)
|
Do
You [ ] Own
or
[ ] Rent |
County
|
How
Long
|
|
Employer
|
Position/Title
|
How
Long
|
|
City
& State
|
Business
Telephone No.
|
Mother's
Maiden Name (last)
|
|
Member
Eligibility
|
Employer
ID/Badge #
|
Office
E-mail
|
|
Name,
Address and Phone # of someone who will always know your
location outside your household
|
Home
E-mail
|
|
|
___________________________________
II. JOINT APPLICANT OR MINOR INFORMATION ___________________________________ |
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
Name, City & State
|
Business
Telephone No.
|
|
|
___________________________________
III. JOINT APPLICANT OR MINOR INFORMATION ___________________________________ |
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
Name, City & State
|
Business
Telephone No.
|
|
|
________________________________________________
IV. ACCOUNT TYPES _______________________________________________ |
|
OWNERSHIP: Please select the type
of ownership and rights at death you want by initialing below. The type
of account you select may determine how property passes on your death.
Your will may not control the disposition of funds held in some of the
accounts. The ownership type/rights at death specified on this
Application remain the same for all accounts listed below. If you are
uncertain about the meaning of the ownership terms used in this section,
please read ACCOUNT TYPES on pages 3 and 4.
____________ Single-Party Account without "P.O.D."
(Payable On Death) Designation (in the name of the member with no rights
at death)
____________ Single-Party Account with "P.O.D." (Payable
On Death) Designation (Name beneficiaries below)
____________ Multiple-Party Account with Right of Survivorship
____________ Multiple-Party Account with Right of Survivorship and
P.O.D. (Payable On Death) Designation (Name beneficiaries below)
____________ Convenience Account (Name cosigner here:
___________________________________________________________________ )
____________ Trust Account (Name beneficiaries below)
____________ Member as Custodian for Minor under the Texas Uniform
Transfers to Minors Act (TUTMA) (Complete Section II. above)
____________ Other
_________________________________________________________________________________________________
To Add Pay-on-Death or Trust Beneficiaries Name One or More Here Along
With Their Address, Phone#, DOB, and SS#:
___________________________________________________________________________________________________________________ |
|
[ ] Master
Savings
[ ] Checking Account
[ ] _______________________________ |
___________________
___________________
___________________ |
[ ] Term Share
Account
[ ] Individual Retirement Account
[ ] _______________________________ |
# of Months
_________
___________________
___________________ |
|
© 1993 Bankers Systems, Inc., St. Cloud, MN
Form MAP-LAZ-TX
1/21/2001 Customized
(page 1 of 4) |