Type of Account
*
Savings
Checking
Business/Non-Profit Checking
Money Market
Share Certificate (CD)
Special Savings
Christmas Club
Health Savings (HSA)
IRA
Other/Specialty Account – Describe Below
Other/Specialty Account
Please describe the specialty account you are interested in & any questions you may have. We will have the appropriate Service Center Representative contact you shortly.
Name
*
First Name
Last Name
Physical Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Is your mailing address the same as your physical address?
Mailing Address
If same as above, please skip
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
SSN#
*
Date of Birth
*
Mother's Maiden Name
*
License Number
*
License Issue Date
*
MM
DD
YYYY
License Expiration Date
*
MM
DD
YYYY
License State
*
Contact Phone
*
(###)
###
####
Contact Email
*
Preferred Method of Contact
*
Either Phone or Email
Email Preferred
Phone Preferred
Best Time to Contact
Hour
Minute
Second
AM
PM
Employer
*
Occupation
*
Length of Employment
Monthly Income
Other Monthly Income
Own/Rent & Monthly Payment
Length at Residence
Joint Borrower?
Type of Account
Savings
Checking
Business/Non-Profit Checking
Money Market
Share Certificate (CD)
Special Savings
Christmas Club
Health Savings (HSA)
IRA
Other/Specialty Account – Describe Below
Other/Specialty Account
Please describe the specialty account you are interested in & any questions you may have. We will have the appropriate Service Center Representative contact you shortly.
Name
First Name
Last Name
Physical Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Is your mailing address the same as your physical address?
Mailing Address
If same as above, please skip
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
SSN#
Date of Birth
Mother's Maiden Name
License Number
License Issue Date
MM
DD
YYYY
License Expiration Date
MM
DD
YYYY
License State
Contact Phone
(###)
###
####
Contact Email
Preferred Method of Contact
Either Phone or Email
Email Preferred
Phone Preferred
Best Time to Contact
Hour
Minute
Second
AM
PM
Employer
Occupation
Monthly Income
Length of Employment
Other Monthly Income
Own/Rent & Monthly Payment
Length at Residence
Are you a US Citizen or Resident Alien as defined by the IRS?
*
The IRS defines a Resident Alien as a person who is not a US citizen, but either has an immigration visa (“green card”), or has resided in the US for at least the last 31 days and at least half of the year in each of the last two years.
Will you send or receive domestic wires with this account regularly?
*
Describe the source of funds being received and/or purpose of the funds being sent, the anticipated dollar amounts, and the foreign countries involved (if any).
Will you send or receive foreign wires with this account regularly?
*
Describe the source of funds being received and/or purpose of the funds being sent, the anticipated dollar amounts, and the foreign countries involved (if any).
How often do you expect to make cash deposits or withdrawals?
*
How often do you expect to conduct EFTs?
*
EFTs are Electronic Funds Transfers, including debit card, ACH, bill payments, and account to account transfers.
I Agree
*
By clicking on "I agree", you authorize us to verify the information you submitted. To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. In certain cases, we may also ask for a copy of your driver’s license or other identifying documents. Five County Credit Union also participates in a national fraud fighting system, which is designed to identify fraudulent banking activity. Any accounts found to be providing false identification or involved in fraudulent activity will be reported to the appropriate law enforcement agency.
By completing and submitting this application, you agree to all terms, and certify that everything you have entered is correct and true.You warrant to us that the information you are submitting is true and correct. By submitting this application, you agree to allow us to receive the information contained in your application, as well as the status of your application. *Open Monday-Friday 8:30am-7:00pm & Saturday 9:00am-3:00pm, including most holidays.
