Alexandria USDA
Federal Credit Union
P. O. Box 4030
Pineville, LA 71361-4030
Eligibility Information | Member Groups | Member Application
Acct. Name Acct. No.
Street
SS/TIN
City State Zip
Date of Birth D/L No.
Place of Birth
Mother's Maiden Name
Employer
Eligibility
Home Phone   (      ) Home E-Mail
Work Phone   (      )
I hereby make application for membership in and agree to conform to the Bylaws, as amended, of Heart of Louisiana Credit Union (the "Credit Union"). I certify that: I am within the field of membership of this Credit Union; the information provided on this application is true and correct; and my signature on this card applies to all accounts under my name at this Credit Union. I also agree to be bound to the terms and conditions of any account that I have in the Credit Union now or in the future.
Signature (Primary) Date
This application approved (date) by the (check one):
( ) Membership Officer     ( ) Board of Directors     ( ) Executive Committee
Credit Union Signature Date

tax identification number certification
and backup withholding information

Under penalties of perjury, I certify that: (1) The number shown on this form is my correct identification number, (2) I am not subject to backup withholding 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 withholding, and (3) I am a U. S. person (including a U. S. resident alien), and that I am, unless designated below, a U. S. person (including a U. S. resident alien).

 

APPLICATION FOR MEMBERSHIP

 
Exempt I am subject to backup withholding.

 

JOINT SHARE ACCOUNT/AGREEMENT/NOT TRANSFERABLE

The Heart of Louisiana Credit Union is hereby authorized to recognize any of the signatures subscribed below in the payment of funds or the transaction of any business for this account. The joint owners of this account hereby agree with each other and with said Credit Union that all sums now paid in on shares, or heretofore or hereafter paid in on shares by any or all of the said joint owners to their credit will be subject to withdrawal or receipt by any of them and they do discharge said Credit Union from any liability for such payment. The joint owners also agree to the terms and conditions of the account established by the Credit Union, and to any charges which may occur from time to time.

The right and authority of the Credit Union under this agreement shall not be changed or terminated by said owners, or any of them except by written notice to said Credit Union which shall not affect transactions theretofore made.
Signature (Primary) Date
 
 
Joint Owner SSN/TIN
Street D/L No
City/State/Zip Date of Birth
Mother's Maiden Name Home E-Mail
Home Phone (      ) Work Phone (      )
Joint Signature Date
 
   
Joint Owner SSN/TIN
Street D/L No
City/State/Zip Date of Birth
Mother's Maiden Name Home E-Mail
Home Phone (      ) Work Phone (      )
Joint Signature Date
.
Joint Owner SSN/TIN
Street D/L No
City/State/Zip Date of Birth
Mother's Maiden Name Home E-Mail
Home Phone (      ) Work Phone (      )
Joint Signature Date
.

TO BE COMPLETED IF ACCOUNT IS FOR A MINOR
   I,________________________________________ establish this account
 under THE UTTMA/UGMA (Uniform Transfers/Gifts to Minors Act) as custodian for
  __________________________________________ (minor).
   Minor's TIN/SSN   __________________________________________________

TO BE COMPLETED FOR PAYABLE ON DEATH ACCOUNTS ONLY
    Payable on Death
   Designate Specific Suffix
(POD/Trust Account)
Beneficiary/POD Payee Beneficiary/POD Payee
______________________________________ ____________________________________
Street________________________________ Street_______________________________
City/State/Zip__________________________ City/State/Zip________________________
Agency - Print Name of Agent ____________________________________
Signature______________________________ Date________________________________