Gateway Credit Union Membership Application

MEMBERSHIP ELIGIBILITY

Residence

Address

City / State / Zip

Work

Employer Name

Family / Relative

Relative’s Name

Relationship

MEMBER INFORMATION

Member Name

Member No.

Address

City / State / Zip

Email

Social Security No.

Birth Date

Home Phone

Cell Phone

Work Phone

Employer

Government Issued ID

ID State

ID Exp. Date

ACCOUNT OWNERSHIP

Add Joint Owner with Right of Survivorship

Joint Owner #1

Member Name

Email

Address

City / State / Zip

SSN

Birth Date

Employer

Home Phone

Cell Phone

Work Phone

Government Issued ID

ID Exp. Date

ID State

Add a second joint owner

Joint Owner #2

Member Name

Email

Address

City / State / Zip

SSN

Birth Date

Employer

Home Phone

Cell Phone

Work Phone

Government Issued ID

ID Exp. Date

ID State

Payable on Death (POD) Beneficiary

All Accounts

Specific Account(s)

Beneficiary

Beneficiary 2

UTMA Account (list minor's name and TIN)

Minor’s Name & TIN

TIN AND BACKUP WITHHOLDING CERTIFICATION

By signing below, I certify under penalties of perjury that: (i) I am a US citizen or other US person, (ii) the Social Security Number (SSN)/Taxpayer Identification Number (TIN) shown is my correct identification number, and (iii) I am NOT, unless designated below, subject to backup withholding...

I am subject to backup withholding

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

I am exempt from withholding

AUTHORIZATION

By signing below, I/we agree to the terms and conditions of the Membership and Account Agreement...