2805 Bowers Avenue Santa Clara, CA 95051 FAX - 408-731-4485

Membership Application

USA PATRIOT ACT NOTICE: To help the government fight funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account. When you open an account, we will ask for your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver's license and other identifying documents .

Primary Member

(PLEASE PRINT - All items must be completed)

_____________________________________________________________________________________________________________________________________________________________________ Photo ID Type First Name Middle Name Last Name _____________________________________________________________________________________________________________________________________________________________________ ID Number City State ZIP Current Address _____________________________________________________________________________________________________________________________________________________________________ City State ZIP Mailing Address Issue State / County / / / / _____________________________________________________________________________________________________________________________________________________________________ Issue Date State ZIP Occupation Expiration Date Employer Name City a Lawful Permanent U.S. / / Other (describe): a U.S. Citizen / / You are: Resident _________________________________________________________________________________________________________________________________________________ 2nd ID Type Taxpayer ID / Social Security Number Expiration Date (W9 required for foreign status) ( ) ( ) / / ______________________________________________________________________________________________________________________________________________ Mother's Maiden Name Residence Telephone Business Telephone/Ext. Birth date (mm/dd/yy) City of Birth YES Are you a senior foreign political figure or a close associate of a senior foreign political figure? Is foreign wire activity anticipated on accounts to be established under this membership? NO _______________________________________________________________________ E-mail Address Work E-mail Address ( ) ________________________________ Cell Phone

Homeowner

Renter

Other

Joint Owner if Desired for Share Accounts

(PLEASE PRINT - All items must be completed)

_____________________________________________________________________________________________________________________________________________________________________ Photo ID Type First Name Middle Name Last Name _____________________________________________________________________________________________________________________________________________________________________ ID Number City State ZIP Current Address _____________________________________________________________________________________________________________________________________________________________________ City State ZIP Issue State / County Mailing Address / / / / _______________________________________________________________________________________________________________________________________________________ Issue Date State City Employer Name Occupation ZIP Expiration Date a Lawful Permanent U.S. / / / / Other (describe): a U.S. Citizen You are: Resident _____________________________________________________________________________________________________________________________________________________________________ Taxpayer ID / Social Security Number 2nd ID Type Expiration Date (W9 required for foreign status) ( ) ( ) / / ________________________________________________________________________________________________________________________________________________________________ Mother's Maiden Name Residence Telephone Business Telephone/Ext. Birth date (mm/dd/yy) City of Birth YES Is joint owner a senior foreign political figure or a close associate of a senior foreign political figure? Is foreign wire activity anticipated on accounts to be established under this membership? NO _____________________________________________________________________ E-mail Address Work E-mail Address ( ) _______________________________ Cell Phone

___________________________________ Relationship to Primary Member

Membership Eligibility
1.

(SELECT ONE OF THE FOUR - All items in your selection must be completed)
3. Live/Work/Worship/Attend (County)

2. _____________________________________________________________________________________________ Employment at: (Company Name) Contract Employee of: (Company Name)

4. _______________________________________________________________________________________________________________________________________________________________ Relationship to Member Family Member's KeyPoint Credit Union Account Number Family Member of: (Primary Member Name)

Accounts
Checking Savings

(SELECT ALL THAT APPLY)
Money Market Certificates: Traditional Term

Applicant Requests All Electronic Services Available, Except Those Checked Below I do not want to enroll in Access 365 (automated telephone access) I do not want to enroll in Online Banking (including Bill Payment) I do not want an ATM Card to access my savings account. I do not want a VISA R Debit Card to access my checking account.
For your convenience and to help conserve environmental resources, your account will be automatically set-up to receive eStatements that can be accessed anytime through Online Banking.

Loan Account Only (Separate application required)

Individual Retirement Accounts
IRA Term

Health Savings Account (HSA)

No thank you, I prefer to receive paper statements in the mail.

Checking Overdraft Protection

(Complete only if Checking is selected)

INSTRUCTIONS: Indicate the account number of the account(s) you wish to debit in the event of an overdraft. (Line of credit transfers are made in $50 increments; If an overdraft option is not selected, checks may automatically be returned). Overdrafts are to be covered by transferring funds from: First Overdraft Account Number _____________________________________________ Second Overdraft Account Number _________________________________________________________

Pay-On-Death

(PLEASE PRINT)

INSTRUCTIONS: If this is a joint account, in the event of the death of one of the joint owners, the other joint owner retains full ownership of all funds in the account. If this is an individual account, then upon the death of the individual owner, funds in the accounts covered by this application will be payable to the individuals named below. If no percentages are shown, distribution will default to equal division. If no beneficiaries are named, funds pass at death to the estate of the last surviving owner. _______________________________________________________________________________________________________________________________________________________ Name (First & Last) Address (Street, City, State, ZIP) _______________________________________________________________________________________________________________________________________________________ Name (First & Last) Address (Street, City, State, ZIP)

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Membership Application and Agreement

By signing this application and submitting it to KeyPoint Credit Union, or by submitting this application to KeyPoint electronically:

1. 2. 3. 4. 5.

The person identified as "MEMBER," if not already a KeyPoint member, applies for membership and certifies under penalty of perjury that the membership eligibility statement is accurately completed. I agree to abide by applicable law and KeyPoint Credit Union's bylaws in all dealings with KeyPoint Credit Union. You are authorized to check my credit and account history, including verification of information on this application. This application constitutes my request for the services indicated on this application and my continuing authorization to open accounts for me under my KeyPoint membership upon my oral or written request and deposit of funds. If a joint owner is indicated, all accounts established under this membership other than IRA will be joint ownership with right of survivorship. Joint owners are equally responsible with members, jointly and individually, for complying with all terms of all agreements with KeyPoint Credit Union. I acknowledge receipt of the KeyPoint Member Handbook, the Truth in Savings Disclosure applicable to any accounts I have opened, and Fee Schedule and consent to their terms as amended from time to time by proper legal notice to me. I agree that if I become indebted to KeyPoint Credit Union in any way, including by use of plastic cards or by overdrawing my checking account, if I do not pay what I owe according to my agreements, you can take any funds voluntarily deposited to KeyPoint share accounts in which I have an interest to recover all or part of what of I what I owe without notice and without waiving other collection rights. This consent applies to all voluntarily deposited funds, including funds that may otherwise be exempt from creditors remedies, such as social security direct deposit, unless prohibited by law or the share agreement. This consent is in addition to any right of the Credit Union to impress a lien on my shares under California Financial Code Sec. 14856 or any equitable right of offset. Substitute W-9 Taxpayer ID Certification: You may request official IRS W-9 instructions from a KeyPoint staff member or, if applying online, click here to obtain instructions at http://www.irs.gov/pub/irs-pdf/fw9.pdf. I declare under penalty of perjury that (a) I am a U.S. Person (including resident alien), (b) the taxpayer ID number provided on this application is correct and (c) either (1) I have never been notified by the IRS that I am subject to backup withholding due to failure to report dividends or interest or (2) I have been notified by the IRS that I am no longer subject to backup withholding. The IRS does not require my consent to any term of any agreement with the Credit Union other than the certifications required to avoid backup withholding. If I am subject to backup withholding, the following box is checked.

6. 7.

8.

INSTRUCTIONS: By completing this application, I request membership in KeyPoint Credit Union. I agree to abide by the laws and bylaws in all dealings with KeyPoint Credit Union. The information that I have stated on the application is true and complete. You are authorized to check my credit history, including verification of information on this application. I acknowledge receipt of and agree that all of my KeyPoint Credit Union accounts will be subject to the KeyPoint Credit Union Master Disclosure/Truth-in-Savings Disclosure and Fee Disclosure as amended from time to time. By signing below, I certify under penalty of perjury that the Taxpayer ID/Social Security number provided on this application is correct and that I am not subject to backup withholding due to underreporting of dividends or interest. I also certify that I am a U.S. person (includes a U.S. resident alien). The IRS does not require my consent to any provisions of the application other than the certification to avoid backup withholding.

__________________________________________________________________________ Date Primary Member Signature

__________________________________________________________________________________ Date Joint Member Signature

Print

OFFICE USE ONLY
Membership Account Number: _______________________________________________ Revised Signature Card: (check all that apply) Name Change Adding Joint New Waived Date: _____/______/______ Staff Initials: ______________
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Other _______________

__________________________________________________________________________ __________________________________________________________________________________ Account Opened by (First & Last Name) / Cash Box Number Chexsystems Manager/Supervisor Approval (I certify that I have checked all of the above information) Promo Code: _____________ (REV. 07/11)