Beaver Valley FCU Membership Application

Thank you for your interest in becoming a member of Beaver Valley Federal Credit Union. If you live, work, worship, or attend school in Beaver County, Pennsylvania, or are part of the immediate family or household of someone who qualifies for membership, you may become a credit union member.

To apply for membership, complete the following application, print it out, have it notarized* and mail it to us along with your initial deposit of at least $5. (This is not a fee, but a deposit into a regular share account.) This initial deposit entitles you to take advantage of a full range of financial services provided by BVFCU.

*Notary is not required if delivered to Beaver Valley FCU in person.

You are also required to provide positive identification; a clear photocopy of your valid Driver's License and Social Security Card. After your account is opened, you will be mailed a copy of your membership agreement containing your new BVFCU Account Number. Click here for U.S. Patriot Act disclosure.

Mail your completed form, check (or money order) and ID to:

Member Services

Beaver Valley FCU

601 - 37th Street

Beaver Falls, PA 15010

Membership Qualification

I am eligible for membership in BVFCU because I :
OR
A member of my household or immediate family :

Live in Beaver County
Work in Beaver County
Worship in Beaver County
Attend school in Beaver County

Name of family or household member if eligibility for credit union membership is through the individual

Primary Owner of Account

Last Name:

First Name:

Maiden Name:

Home Address: (Not P.O. Box)	City:	State:	Zip Code:
How long have you been at this address? mo years, If less than 6 months,
Previous Address: (Not P.O. Box)	City:	State:	Zip Code:

Social Security Number

Date of Birth:

Home Phone Number: (with area code)

Employer Name
Employer Address

Mother's Maiden Name

Driver's License Number:

State:

Personal Contact (Relative or close personal friend not living in the same household.)
Name:	Relationship:	Phone Number:

Joint Owner #1

Relationship to Primary Member:

Last Name:

First Name:

Home Address: (Not P.O. Box)

City:

State:

Zip Code:

Social Security Number

Date of Birth:

Home Phone Number:

Mother's Maiden Name

Driver's License Number:

State:

Joint Owner #2

Relationship to Primary Member:

Last Name:

First Name:

Home Address: (Not P.O. Box)

City:

State:

Zip Code:

Social Security Number

Date of Birth:

Home Phone Number:

Mother's Maiden Name

Driver's License Number:

State:

Joint Owner #3

Relationship to Primary Member:

Last Name:

First Name:

Home Address: (Not P.O. Box)

City:

State:

Zip Code:

Social Security Number

Date of Birth:

Home Phone Number:

Mother's Maiden Name

Driver's License Number:

State:

TIN CERTIFICATION AND BACKUP WITHOLDING INFORMATION

TIN CERTIFICATION AND BACKUP WITHOLDING INFORMATION Under penalties of perjury, I certify that:
(1) The Taxpayer Identification Number (TIN) shown above is my correct TIN.
(2) I am not subject to backup withholding because: (a) 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 (b) 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).

Certification Instructions: Cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. Cross out item 3 and complete a W-8 BEN if you are not a U.S. person.

AUTHORIZATION

By signing below, I/we agree to the terms and conditions of the Membership and Account Agreement, Truth-in-Savings Disclosure, Funds Availability Policy Disclosure, if applicable, and to any amendment the Credit Union makes from time to time which are incorporated herein. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

______________________________________________
Print Full Name of Primary Member

Please Note: Your signature must be notarized if it is not signed in the prescence of a
Beaver Valley FCU representative.

X________________________________ Member Signature	X_________________ Date
X________________________________ Joint Owner #1 Signature	X_________________ Date
X________________________________ Joint Owner #2 Signature	X_________________ Date
X________________________________ Joint Owner #3 Signature	X_________________ Date