| Meridian Mutual Federal Credit Union Membership Application Please print this form, fill it out and fax to 601-482-5748 Close this Page |
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IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT To help the Government fight the 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. WHAT THIS MEANS FOR YOU: 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 will also ask to see your driver’s license or other identifying documents. |
| General Information: | |
Will there be a co-applicant on this application?  No Yes, 1 co-applicant Yes, 2 co-applicants |
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| Membership Eligibility: | |
| Employer |
Employer Name: |
| Family
Member |
Family Name: |
| Community |
Community Name: |
| Primary Applicant: | |
| Last Name: | Middle Name: |
| First Name: | Social Security Number (TIN): |
| Date of Birth: | Home Phone Number: |
| Work Phone Number: | Other Phone Number: |
| Email Address: | Mother's Maiden Name |
| I certify that: The TIN is correct and I ( am / am not ) subject to back-up withholding (Circle One) and I am a U.S. Person (including a U.S. Resident Alien). |
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| Drivers License #: | Drivers License State: |
| Home Address (not P.O. Box) | |
| Address 1: | |
| Address 2: | |
| City: | State, Zip: |
| Time at Current Residence: | Residence Type: Own Rent Other: |
| Mailing Address (if different) | |
| Address 1: | |
| Address 2: | |
| City: | State, Zip: |
| Employment History | |
| Present Employer Name: | Employer Phone Number: |
| Employer's Address 1: | |
| Employer's Address 2: | |
| City: | State, Zip: |
| Job Title: | Job Start Date: |
| References | |
| Nearest Relative Not Living With You | |
| Last Name: | First Name: |
| Relationship: | Phone Number: |
| Address 1: | |
| Address 2: | |
| City: | State, Zip: |
| Additional Information |
| How would you prefer to be contacted? Home Phone Work Phone Other Phone Email Address Other: |
| Special Instructions/Comments: |
| Signature | |
| The Internal Revenue Service does not require your consent to any provision of this contract other than the certifications required to avoid backup withholding. | |
| Signature: | Date: |
If this is for a joint account
Print this page and then click here for the
co-applicant form.