MEMBER INFORMATION

Due to the implementation of the Patriot Act, in October 2003, the Dawson Co-op Credit Union is required to obtain copies of documents to identify our members.  Once you have completed the form below, please bring your driver's license/identification card and Social Security Card, along with the form into the Dawson Co-op Credit Union. Also a $10.00 membership share is required to open the account.

Name: 
Address: 
City:  State:  Zip:  SSN/TIN: 
Phone:  Date of Birth: 
Driver Lic. #: MMN: 
Present Employer: 
Address: 
Phone: 
I Qualify for membership in this Credit Union because: 
Name of someone who will always know your location: 
Address: 

JOINT OWNERS/MINOR INFORMATION

Name: 
Address: 
City:  State:  Zip:  SSN/TIN: 
Phone:  Date of Birth: 
Driver Lic. #: MMN: 
Name: 
Address: 
City:  State:  Zip:  SSN/TIN: 
Phone:  Date of Birth: 
Driver Lic. #: MMN: 

OWNERSHIP OF ACCOUNT

SELECT ONE OWNERSHIP TYPE AND, IF APPLICABLE, INCLUDE A BENEFICIARY DESIGNATION. THE OWNERSHIP TYPE AND BENEFICIARY DESIGNATION SPECIFIED ON THIS DOCUMENT WILL REMAIN THE SAME FOR ALL ACCOUNTS LISTED BELOW
 

1. Individual                  2. JOINT WITH SURVIVORSHIP (and not as tenants in common)
3. MEMBER AS CUSTODIAN FOR MINOR UNDER THE MINNESOTA UNIFORM TRANSFERS TO MINORS ACT (UTMA)
4. TRUST - SEPARATE AGREEMENT DATED: 
5.
BENEFICIARIES REVOCABLE TRUST OR PAY-ON-DEATH DESIGNATION AS DEFINED IN THE ACCOUNT TERMS AND CONDITIONS: (Place name and address of beneficiaries below)
Name: 
Address: 
City:  State:  Zip: 
 
 
 
 

SIGNATURES & CERTIFICATIONS

BACKUP WITHHOLDING CERTIFICATION - Check box (A) only if true or (B) below:

(a) By signing below, I (name): certify under penalties of perjury that (1) the Taxpayer Identification Number (TIN) shown above is my correct TIN and I am not subject to backup withholding either because (a) I have not been notified by the Internal Revenue Service that I am subject to backup withholding as a result of failure to report all interest or dividends or (b) the IRS has notified me that I am no longer subject to backup withholding.
(b) A separate Certification has been completed.
By signing below, the undersigned agree to the Credit Union by-laws and the terms and conditions of any approved account, as amended from time to time, and authorize the Credit Union to verify credit and employment history by any necessary means, including preparation of a credit report by a credit reporting agency. The undersigned certify that the information provided on this application is true and correct and that the terms on this application apply to all listed accounts. The undersigned acknowledge receipt of a copy of the terms and conditions applicable to each listed account and the following policy disclosures:

Funds Availability Truth-In-Savings Electronic Fund Transfers


THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING.
(1) X __________________________________________________________ ________________________
Member Signature
(Date)
 Member/Account #
(2) X __________________________________________________________ ________________________
Signature
(Date)
 Relationship to Member
(3) X __________________________________________________________ ________________________
Signature
(Date)
 Relationship to Member

AGENTS - THE INDIVIDUAL SIGNING ABOVE ON LINE IS SIGNING AS:

Power of attorney - agreement on file  A Successor Custodian of a UTMA account  Parent/Guardian
Authorized Signer