ACCOUNT CARD Individual/Joint/POD Account# I am eligible to join by:

ACCOUNT CARD
Account#
Individual/Joint/POD
I am eligible to join by:
Eligible Group Affiliation
Sponsored by a Family/Household Member
Member of California or American Consumer Council
I wish to join California or American Consumer Council and the credit union
ACCOUNT TYPE
New Account
Updating Account
Savings Account
Checking
Type
Sub Savings
Holiday Club
Term
Money Market
Certificate
CHANGES TO AN EXISTING ACCOUNT
Add Joint Owner(s)
*This account card supercedes
Add Beneficiary(ies)
all previous account cards on
file with NuVision.
Remove Joint Owners(s)
Remove Beneficiaries(ies)
Maturity Date
Name Change/Also Know As
PRIMARY MEMBER INFORMATION
Name
Social Security Number Identification Number
Street Address
City
Mothers Maiden Name
AKA
State
State Expiration Date Date of Birth
Zip
Home Phone#
E-mail Address
Work Phone #
Occupation/Field/Position
Chexsystems verification
(CU use only)
JOINT OWNER INFORMATION
Name
Social Security No. Identification
Street Address
City
Mothers Maiden Name
AKA
Name
Social Security No. Identification
Street Address
City
Mothers Maiden Name
AKA
State
State
Zip
Expiration Date
Home Phone#
Date of Birth
Work Phone #
E-mail Address
State
State
Zip
Occupation/Field/Position
Chexsystems verification (CU use only)
Relationship
Expiration Date
Home Phone#
Date of Birth
Work Phone #
E-mail Address
Occupation/Field/Position
Chexsystems verification (CU use only)
Relationship
ACCOUNT TYPE(S)
SUBSHARE JOINT OWNER INFORMATION
Relationship
Account Suffix
Mothers Maiden Name
Name
Social Security No. Identification
Street Address
City
Relationship
Account Suffix
Name
Social Security No. Identification
Street Address
City
Relationship
Account Suffix
Name
Social Security No. Identification
Street Address
City
Chexsystems verification (CU use only)
1
2
State
State
Zip
Expiration Date
Home Phone#
Date of Birth
Work Phone #
Mothers Maiden Name
State
State
Zip
E-mail Address
Chexsystems verification (CU use only)
Expiration Date
Home Phone#
Occupation/Field/Position
Date of Birth
Work Phone #
Mothers Maiden Name
Occupation/Field/Position
E-mail Address
Chexsystems verification (CU use only)
3
Page 1 of 3
State
State
Zip
Expiration Date
Home Phone#
Date of Birth
Work Phone #
Occupation/Field/Position
E-mail Address
Revised 02/13 WB
ACCOUNT CARD
Individual/Joint/POD
SUBSHARE JOINT OWNER INFORMATION
Relationship
Account Suffix
Mothers Maiden Name
Name
Social Security No. Identification
Street Address
City
ChexSystems verification (CU use only)
4
BENEFICIARY INFORMATION
State
State
Zip
Expiration Date
Home Phone#
Date of Birth
Work Phone #
Occupation/Field/Position
E-mail Address
Upon death of the last account owner the following individual(s) become(s) Beneficiary or Beneficiaries.
Account Suffix
1
Name
Social Security Number Relationship
Date of Birth
OFAC verification (CU use only)
Social Security Number Relationship
Date of Birth
OFAC verification (CU use only)
Social Security Number Relationship
Date of Birth
OFAC verification (CU use only)
Social Security Number Relationship
Date of Birth
ChexSystems verification (CU use only)
Account Suffix
2
Name
Account Suffix
3
Name
Account Suffix
4
Name
DEBIT/ATM CARD(S)
Debit/ATM Cards are issued based on eligibility and are subject to Terms and Condition as outline in the NuVision Federal Credit Union Electronic Funds
Transfer Agreement and Disclosure.
If eligible, the card and personal identification number (PIN) will be mailed to you separately to allow you to gain access to your account. Eligibility is
determined by performing an inquiry through ChexSystems. Refer to the Schedule of Fees and Charges for applicable fees.
Debit Cards are issued to accounts having both a checking and savings account. ATM cards are issued to accounts with savings only
Card Requested For:
Primary Owner
Joint Owner
Was the Card issued today?
Yes
No
CHECKING OVERDRAFT PROTECTION
Checking account overdrafts can be cleared by a transfer (or advance) from an established account(s). A Cross Account Transfer Form must be
completed to allow transfers from a different account number. Refer to the Schedule of Fees and Charges for applicable fees and transfer limitations.
Indicate your preference of sequence below by using 1, 2, 3.
Transfer from my Savings
Suffix
Suffix
Suffix
Transfer from my Money Market
Advance from my Line of Credit up to my credit limit, subject to the terms and conditions of that account, such sum(s) as established by NuVision
Federal Credit Union from time to time.
Page 2 of 3
Revised 02/13 DS
Account#
ACCOUNT CARD
Individual/Joint/POD
NEW ACCOUNT QUESTIONNAIRE
Source of funds to be deposited into this account:
Future deposits will consist of (all that apply):
Future withdrawals will consist of (all that apply):
Cash (if less than $3000 then n/a)
Average amount $
Cash (if less than $3000 then n/a) Average amount $
Wire
Average amount $
Wire
Average amount $
ACH (such as PayPal, etc).
Average amount $
ACH (such as PayPal, etc).
Average amount $
Check
Check
Direct Deposit
Debit Card
ATM Card
Average Household Income: $
TAX CERTIFICATION – UNDER PENALTIES OF PERJURY, I CERTIFY THAT
(1)The number on this form is my correct taxpayer identification number
(2) I am not subject to backup withholding because (a) I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, (b) the
Internal Revenue Service has notified me that I am no longer subject to backup withholding, or (c) this account is owned by an entity exempt from backup dividends.
(3)Check this box
(4)
if you are subject to backup withholding and cannot certify the provision of (2) above.
If this box is checked, the above 1-3 of the Tax Certification do not apply because (a) I am not a United States person or (b) I am an individual and am neither a citizen nor a resident
of the United States. I will complete the IRS form W-8 BEN (c) if this is not checked, I am a U.S. Citizen. (including U.S. resident alien).
1. You promise that everything you have stated in this application is correct. Your authorize NuVision Federal Credit Union to check your employment and credit history and to obtain credit
reports in connection with your request for membership and/or credit and for any update, renewal or extension of the credit received. You understand that NuVision Federal Credit Union
will rely on the information above and in your credit reports. If there are any important changes, you will notify us in writing immediately. You also agree to notify us of any changes in
your name, address, or employment within a reasonable time thereafter.
2. By signing below you acknowledge receipt of a copy of the Agreements & Disclosures, Rate Schedule, Schedule of Fees & Charges, and Security Agreement, including the Addendum and a
Credit Insurance Certificate. By signing below you agree to the terms and conditions of each of the agreements/disclosures applicable to the accounts and services elected above and any
amendments NuVision Federal Credit Union makes from time to time which are incorporated herein.
3. I understand I will be given access to the ABIL (Automated Telephone Transaction) System.
4.
Pursuant to federal law, NuVision Federal Credit Union must verify the identity of any person seeking to open an account or add a joint owner to any existing account and will maintain
records of the information used to verify the person’s identity.
By signing below you have read and acknowledged the conditions of the Account and Service Election form you selected, unless stated otherwise.
Signature of Primary Account Holder
Date
Signature of Joint Account Holder (1)
Date
Signature of Subshare
Account Holder (1)
Date
Signature of Subshare
Account Holder (2)
Signature of Joint Account Holder (2)
Date
Signature of Subshare
Account Holder (3)
Date
Date
Date
Signature of Subshare
Account Holder (4)
NUVISION CREDIT UNION USE ONLY
ACCOUNT OPENED BY:
SUPERVISOR/MANAGER APPROVAL
Operator #
Date
Mail-In
In Branch
Internet
Signix
Page 3 of 3
Approved by (initials)
PRIVACY NOTICE AND OPT-OUT
Resident of California
Notice Mailed Out
Notice given during
account opening
Date received
Date
Revised 02/13 DS