EFTA00133709

Account Number:		Basis for Membership:
Please tell us about yourself
☐ ChexSystems:

Last Name	First Name			Middle Name	Suffix (Jr. Sr. II)
Date of Birth	Social Security Number	Mother's Maiden Name		Home Phone Number
Street Address (including Apt. #)		BROOKLYN		NY	11214
Street Address (including Apt. #)		City		State	ZIP
Mailing Address (including Apt. #)		City		State	ZIP
FED. BUREAU OF PRISON		PO BOX 1043		Employer's Address
NY	NY	10013
City	State	ZIP	Work Phone Number	Cell Phone Number
Email Address
State Drivers License		NY		02/26/13
ID 1 Type:	ID 1 Number	ID 1 Description		ID 1 Expiration Date
ID 2 Type:	ID 2 Number	ID 2 Description		ID 2 Expiration Date
ID 3 Type:	ID 3 Number	ID 3 Description		ID 3 Expiration Date
Joint Account Holder
☐ ChexSystems:

Last Name	First Name			Middle Name	Suffix (Jr. Sr. II)
Date of Birth	Social Security Number	Mother's Maiden Name		Home Phone Number
Street Address (including Apt. #)		City		State	ZIP
Street Address (including Apt. #)		City		State	ZIP
Mailing Address (including Apt. #)		City		State	ZIP
Employer	Employer's Address
City	State	ZIP	Work Phone Number	Cell Phone Number
Email Address
Re-type Email Address (for verification)
ID 1 Type:	ID 1 Number	ID 1 Description		ID 1 Expiration Date
ID 2 Type:	ID 2 Number	ID 2 Description		ID 2 Expiration Date
ID 3 Type:	ID 3 Number	ID 3 Description		ID 3 Expiration Date

EFTA00133710 # Beneficiary Information (optional) | Last Name | First Name | Middle Name | Suffix (Jr. Sr. II) | | :--- | :--- | :--- | :--- | | Date of Birth | Social Security Number | Relationship to member | Home Phone Number | | Street Address (including Apt. #) | City | State | ZIP | **BRROKLYN** *NY* *11214* --- # Beneficiary Information (optional) | Last Name | First Name | Middle Name | Suffix (Jr. Sr. II) | | :--- | :--- | :--- | :--- | | Date of Birth | Social Security Number | Relationship to member | Home Phone Number | | Street Address (including Apt. #) | City | State | ZIP | **BROOKLYN** *NY* *11214* --- ## Accounts/Services To Open: - **Shares** - **FasTrack Checking** - **ATM/Check Card** - **Alternative Checking** - **Money Market** - **Touch Tone Teller** - **MCU OnLine** - **Order Checks** Date: 09/25/07 I hereby apply for membership and subscribe for at least one share ($5.00) in the Municipal Credit Union and agree to conform to its By-Laws and amendments thereof. I agree to be governed by the Account Agreement, Rules and Regulations and Schedule of Dividends, Service Charges and Fees of the Municipal Credit Union applicable to Share, FasTrack Checking, Vacation, Holiday and Money Market accounts as now in effect and as from time to time amended. I agree to be bound by the terms and conditions contained in the MCU Cash Connection, MCU ATM/Check Card and/or Touch Tone Teller Agreements which will be mailed to me if I elect to receive such service(s). Also, I have received and agree to be bound by the forms and conditions of the MCU OnLine agreement upon my first use of MCU OnLine service(s). I understand that the designations made on this signature card/form will apply to all MCU deposit accounts which are or will be in the future maintained under the same root account number (except IRA, Youth Club, and Share Certificate accounts), and will have the effect of revoking all previous designations made with regard to such accounts. If a joint tenant has been designated on this signature card, it is agreed that these accounts be payable to either of us and upon the death of one of us, to the survivor. Also, it is agreed that any joint tenant may, without the consent of or notice to the other, pledge all or any part of the shares in these accounts as collateral security for a loan with MCU. If a beneficiary (beneficiaries) has (or have) been designated on this signature card, it is agreed that this is a voluntary and revocable trust, and that upon my/our death, the funds in these accounts, and all other deposit accounts maintained under the same root account number (except IRA, Youth Club, and Share Certificate accounts), will become the property of the named beneficiary or beneficiaries who are alive at the time of my/our death in equal proportions. If both a joint tenant and a beneficiary (or beneficiaries) have been designated on this signature card, it is agreed that the beneficiary(ies) will only acquire an interest in these accounts upon the death of the last surviving joint tenant. By signing below, I/We authorize Municipal Credit Union to perform a credit investigation including the verification of the information on this application. Verification of income and employment may also be required. Under penalties of perjury, I certify (1) that the number shown on this form is my current taxpayer identification number; and (2) that I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of failure to report all interest or dividends, or because the Internal Revenue Service has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. citizen (including a U.S. resident alien). The Internal Revenue Service does not require your consent to any provision of this document other that the certifications required to avoid backup withholding.

		09/25/07
Account Holder Signature		Date
Joint Account Holder Signature		Date
☐ Yes, I elect to accept the Check Imaging option and agree to pay the associated service charge.
☐ If Joint Account Holder requests an MCU ATM/Check Card, check this box.
	Manhattan Branch	ROSANNA TEJEDA
Sponsor Account Number	Branch Name	Member Service Representative