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 
