||Name(To be filled in by credit union)|
|Type of I.D.
|Husband's first or Wife's maiden
||Bus. Phone||Home Phone|
|Dept. or Occupation
||Place of Birth|
|Date of Birth
||Mother's maiden name|
||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)
( )Exec. committee
( )Membership Officer
(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.