| Print and complete the following form and send or fax to your Credit Union. | |||
| Torrance Office | Anna Office | East Liberty Office | Marysville Office |
| P.O. Box 2290 | 12500 Meranda Rd | 11000 S.R. 347 | 19775 S.R. 739 |
| Torrance CA 90509-9874 | Anna, OH 45302 | East Liberty, OH 43319 | Marysville, OH 43040 |
| Fax: (310) 972-7002 | Fax: (937) 498-5618 | Fax: (937) 644-6768 | Fax: (937) 642-5184 |
1. Establish Membership |
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| Applicant Name ("Member")________________________________________________________ |
______________________________________ Social Security Number |
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_________________________________________ E-Mail Address |
_________________ Date of Birth |
_____________________ Mother's Maiden Name |
___________________ Monthly Gross Income |
__________________________________________________ Street Address |
__________________________ City |
_________________ State |
___________________ Zip Code |
(___)______________________________ Home Telephone |
(___)______________________________ Work Telephone |
_______________________________________________ Employer |
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2. Eligibility |
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| You are eligible for membership because: | ||
| []You are a Honda Associate: | Associate #______________ | OR [] You are a family
member of a Member or a Honda Associate |
_____________________________________________________ Sponsoring Associate's Name |
_____________________________________________________ Relationship to Member/Associate |
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3. Account Access and E-Mail Disclosure Authorization |
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Additional Account Access |
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| Indicate if You would like to establish any of the following additional means of accessing Your Account: | ||
| [] ATM Card Access | [] Internet Banking Withdrawals and Transfers | [] Audrey Audio Response System Withdrawals and Transfers |
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E-Mail Authorization |
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[] You would like to receive important disclosures required by law,
account records and/or other important information concerning Your Account and/or Account services
via electronic communication directed to the E-Mail address indicated herein. |
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4. Taxpayer Identification and Backup Withholding |
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Under penalties of perjury, You certify (1) that the number shown on this form
is Your correct taxpayer identification and (2) that You are not subject to backup withholding either because
You have not been notified that You are subject to backup withholding as result of a failure to report all interest
dividends, or the Internal Revenue Service (IRS) has notified You that You are no longer subject to backup withholding. 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 have not received a notice from the IRS that the backup withholding has terminated, You must strike out the language in part(2) of the statement above. (3) I am a U.S. person (including a U.S. resident alien). CERTIFICATION IF AWAITING NUMBER Under penalties of perjury, You certify (1) that a taxpayer identification number has not been issued to You and that You mailed or delivered an application to receive a taxpayer identification numberto the appropriate Internal Revenue Service Center or Social Security Administration Office (or You intend to mail or deliver an application in the near future), and (2) that You are not subject to backup withholding. You understand that if You do not provide a taxpayer identification number to the Credit Union within 60 days, the Credit Union is required to withhold 31 percent of all reportable payments thereafter made to You until You provide a number. |
5. Signatures |
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By signing below, You hereby apply for membership with Honda Federal Credit Union. If your application for membership
is approved, a Primary Share Account will be established on Your behalf which must be maintained to continue Your eligibility
for membership. You understand and agree to be bound by the terms and conditions found within this Membership Application; the bylaws, rules and
regulations of Honda Federal Credit Union in effect from time to time; and the terms and conditions
found within the "Agreements and Disclosures" provided in conjunction with this Membership Application for all Accounts or Account Services
established on Your behalf. You acknowledge receiving a copy of those Agreements and Disclosures and You agree to and accept the terms found therein. If You
have selected E-Mail Authorization set forth in paragraph 3 of this Agreement, You understand that any such disclosures and/or information will only be sent in the manner described therein
unless such authorization is revoked by You in writing within a reasonable time prior to the date of the communication
You wish sent to You by some alternate means. In addition to Your Primary Share Account, You may request from time to time
additional Accounts and/or Account services be established
on Your behalf and/or the addition of joint owners to Your Account(S), Your signature below is Your continuing authorization for Us
to follow Your written or verbal instructions to do so and You agree that Your continuing authorization will remain in effect
unless We receive written instructions to the contrary. Subject to applicable laws and regulations, You
further authorize any person, association, firm, corporation personnel office or credit reporting agency to furnish, upon
Our request, information concerning Your employment, credit standing and financial responsibility. In addition
to using this information to evaluate Your continuing eligibility for membership, it may also be used to pre-determine
Your possible eligibility for various Honda Federal Credit Union products and services. Your signature also acknowledges that You have read section 4, Taxpayer Identification and Backup Withholding, and have made any necessary changes. THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PORVISIONS OF THIS DOCUMENT OTHER THAN THE CLARIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING. |
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______________________________________________ Applicant's Signature |
___________________________ Date |
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Credit Union Use Only |
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___________________________________________ Member Number |
_______________________________ Lookup |
_______________________________ Opened By |
_________________ Date |
___________________________________________________________________ Sponsor's Account Number |
________________________________________ Membership Officer Approval |
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[] Eligibility Verified [] o/o |
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