Home  |  About Indiana Members  |  Contact Us    
Membership Application

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Social Security #:

Mother's Maiden Name:
Company/Employer:
E-mail:
Day Phone:

Evening Phone: 


Joint Information:
 

Name:

Social Security #:

E-mail:

Day Phone:


Membership Details:
 
Desired Account Type(s):  

(Check all that apply)      

  Membership Savings (Required)

 

  Regular Checking

 

  MasterMoney Debit Card

 

  ATM Card

 

  Christmas Club

Eligibility: 

 
  Residence

 

  My Employer

Employer's Name: 

I qualify for membership through: 

 

 

  My relative who is a member of the credit union, or an

 

employee of:  

Question or Concern:


Signature:

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 has notified me that I am no longer subject to backup withholding. (The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid backup withholding.)

Please Read Disclosures below:

Fee Disclosure
NetTeller & iPay Agreement
Indiana Members Credit Union Account Agreement and Disclosure