167th TFR Federal Credit Union Membership
Application
Please print this form, fill it out and fax to 304.267.9476
General Information:
Will there be a
co-applicant on this application? No Yes, 1 co-applicant Yes, 2 co-applicants
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).
Drivers License #:
Drivers License State:
Drivers License Expiration
Date:
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.
No 
