New Horizons CCU Membership / New Accounts Application
IMPORTANT INFORMATION ABOUT PROCEDURES FOR ESTABLISHING MEMBERSHIP/NEW ACCOUNTS.
To assist the government fight the funding of terrorism and money laundering activities, the USA PATRIOT ACT 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, SSN, and other information that will allow us to identify you. New Horizons Community Credit Union will maintain the confidentiality of any information obtained in accordance with New Horizons Community Credit Union's privacy policy and applicable laws and regulations.
NHCCU reserves the right to request additional information to support your identity at any time during the membership application process in order to comply with the USA PATRIOT ACT.

PLEASE NOTE: Required fields are marked with an asterisk(*).

Primary Member Information

Name * (Last, First Middle)

Social Security Number (SSN) or TIN *

Date of Birth *
Driver's License * Number | State:

Date Issued | Expiration Date:


Trade Name, Trust Name, Estate Name, or Club Name (if applicable):
Physical Address *

City | State | Zip Code:
 Mailing Address

City | State | Zip Code:
Phone Numbers
Home: Work: Cell:
Personal E-mail Address *
Existing Member Number (to add accounts/services to an existing membership)

Accounts

Accounts Requested
Savings
Checking
Debit Card
NOTE: By checking this box you also acknowledge acceptance of the Debit Card Agreement
Christmas Club Account
Vacation Club Account
Money Market Account
Club / Organizational Account
Ugma / Utma
Successor Trustee:

Membership Affiliation:
Employer
Community
Other, please specify:
Are you in the market to:
Purchase / Refinance a Home
Purchase a New or Used Auto
Take Out / Refinance a Second Mortgage
Receive Financial Planning
Other, please specify:

Authorized Signers

Parties listed herein will be deemed joint owners unless otherwise specified
Trustee
 Custodian   		 Other, please specify:
Authorized Signer 1.
Name:
 		 SSN | Date of Birth
   		 Driver's License / ID # | State
   
Authorized Signer 2.
Name:
 		 SSN | Date of Birth
   		 Driver's License / ID # | State
 
Authorized Signer 3.
Name:
 		 SSN | Date of Birth
   		 Driver's License / ID # | State
   

Payable On Death (POD) Designation

POD Beneficiary 1.
Name:

Relationship | SSN

Date of Birth | Percentage
%
Address:
 POD Beneficiary 2.
Name:

Relationship | SSN

Date of Birth | Percentage
%
Address:

Certification As To Taxpayer Identification Number and Backup Withholding

By submitting this application I certify under penalty of perjury that: 1. The SSN or employer identification number on this form is my correct TIN; 2. I am NOT subject to backup withholding due to failure to report interest and dividend income; 3. I am a U.S. person (including a U.S. resident alien). The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

Check here if you are subject to backup withholding.

Promotion Code

If you are responding to a promotion in an advertisement, please enter the respective Promo Code here:

Agreement

I/we make application for the account(s) and/or membership as indicated and agree to conform to Bylaws, as may be amended, of New Horizons Community Credit Union ("Credit Union"). I certify that I am within the field of membership of this Credit Union if membership is requested. I/we certify the signature(s) on this card apply to all accounts designated above; and all information provided is true and correct. I also acknowledge that I “have received and agree to be bound by and terms and conditions in this card, and in the Membership Account Agreement, Debit Card Agreement and Disclosure, Truth-in-Savings Act, Rate and Fee Schedule, and any Special Account or other separate Account Service Applications or Agreements as amended from time to time, which are incorporated herein by reference. All present and future deposits to the account(s) designated above secure payment of any account owner's obligations to the Credit Union. This card authorizes the Credit Union to open future subaccounts and/or services in the names of the owners or Account Title listed above. Checks may be printed using the names of all joint owners, and the address and home phone number of the Member as they appear above if checking is specified.
By signing below, I/we am(are) agreeing to the following:

  1. to subscribe for at least one (1) share at a par value of $5;
  2. that the Credit Union is authorized to recognize any of the signatures subscribed below for the transaction of any business on any account on which that party is named as an owner;
  3. that all funds paid into any account shall be considered as being held by each owner of the account equally, with right of survivorship;
  4. that any Club Account designated with this document will maintain the same owners as indicated for my regular share account;
  5. that New Horizons Community Credit Union uses referral services that include but are not limited to ChexSystems, and if a negative response is received, New Horizons Community Credit Union maintains the right to refuse a service and/or close the account;
  6. that the Credit Union also reserves the right to pull a Credit Bureau upon opening this account.

* I agree to conform to the bylaws stated above.