Application For Membership To the
Schenectady County Employees Federal Credit Union

Please print this form and bring it to the office of the credit union with proper identification.
Account Number

Name(To be filled in by credit union)
Type of I.D.

I.D. No.
Complete Address

Husband's first or Wife's maiden name

Employer

Bus. Phone Home Phone
Dept. or Occupation

Place of Birth
Date of Birth

Mother's maiden name
Membership Eligibility

Soc. Sec. No. or Tax ident. No.
By signing the bottom of this form, I hereby make application for membership in and agree to conform to the bylaws and any amendments thereof in the SCHENECTADY COUNTY EMPLOYEES FEDERAL CREDIT UNION.
I also agree to the terms and conditions of any account that I have in the credit union now or in the future and agree that the credit union may change those terms and conditions from time to tiime. This application approved by the: (Check one)
(   )Board
(   )Exec. committee
(   )Membership Officer
Date__________________________________
Signed________________________________
(person representing approver of application)

(Instruction to signer: If you have been notified by the Internal Revenue Service (IRS) that you are subject to backup withholding due to payee underreporting and you hve not received a notice from the IRS that the backup withholding has terminated, you must strike out the language in clause 2 of the certification you sign below.)

CERTIFICATION AS TO TAXPAYER IDENTIFICATION NUMBER AND BACKUP WITHHOLDING

Under penalties of perjury, I certify (1) that the number shown on this form is my correct 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 a failure to report all interest or dividends, or the Internal Revenue Service (IRS) has notified me that I am no longer subject to backup withholding.

Signature__________________________ Date _______________________