The Membership Application should be printed and returned to the Credit Union with a $5.00 check to join the Credit Union. Two forms of ID are required. One form of ID must be a picture ID or a birth certificate.
Applicant:
Name: Type of ID:
ID No.: S.S. or Tax I.D. No.:
Address: City/State/Zip
Phone: Employer
Dept. or Occupation Work Phone
Husband's First Name or Wife's Maiden Name:
Mother's Maiden Name
Date of Birth Place of Birth
Basis for Eligibility

I hereby make application for membership in and agree to conform to the bylaws and any amendments thereof in the Peoria Bell Credit Union. I also agree to the terms and conditions of ay account that I have in the credit union now or in the future and agree that the credit union may change those terms and conditions from time to time.


Signature of Member
(Please sign within the box)

This application approved by the: (check one)
Board Exec. Committee Membership Officer

_______________________________________________
Signature (Person representing approver of application)

__________________________
Date

CERTIFICATION AS TO TAXPAYER IDENTIFICATION NUMBER AND BACKUP WITHHOLDING

(Instruction to Signer: If you have been notified by the Internal Revenue Service (IRS) that you are subject to backup withholding due to payee underreporting and you have not received a notice from the IRS that the backup withholding has terminated, you must strike out the language in clause 2 of the certification you sign below.)

Under penalties of perjury, I certify (1) that the number shown on this form is my correct taxpayer identification number and (2) that I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Service (IRS) has notified me that I am no longer subject to backup withholding.

____________________________________
Signature

 _________________________
Date
JOINT SHARE ACCOUNT AGREEMENT

We agree with each other and the credit union that all funds paid into or deposited in this account, including any earnings thereon, shall be owned by us jointly, with the right of survivorship. On the death of one party to this joint account, all sums in the account on the date of the death vest in and belong to the surviving party as his or her separate property and estate. If we are married to each other, any sums in the account which constitute community property become the property of the surviving spouse on the death of a spouse.

Payment of funds in this account may be made upon request of any of us. Any payments made at the request of us or any other person with the right to request payment discharges the credit union from any liability for such payments. Subject to the policies of the board of directors regarding account transactions of member and non-member joint owners, without the necessity of withdrawing the funds in this account and without liability to the credit union, any one of us may, by written notice to the credit union, terminate the interest of any other joint owner. We agree that this account and agreement are subject to any and all rules, regulations, bylaws, and policies of the credit union and its board of directors now in effect and as amended or adopted hereafter, and agree to pay any charges or fees which may be required or assessed under such rules, regulations, bylaws, and policies.

We understand that an attorney should be consulted regarding the validity of any person's survivorship rights to any funds in this account or the fitness of this account or agreement for any particular purpose.

____________________________________
Joint Account No.

 _________________________
Date
   
Soc. Sec. or Tax ID No.
_________________________
Joint Owners (each must sign)
Date of Birth
Soc. Sec. or Tax ID No.
_________________________
Joint Owners (each must sign)
Date of Birth
Soc. Sec. or Tax ID No.
_________________________
Joint Owners (each must sign)
Date of Birth
P.O.D. (PAYABLE ON DEATH) ACCOUNT AGREEMENT

I (We) agree with the credit union that the person(s) named below is (are) designated as P.O.D. payees(s). During my (our) lifetime, all funds paid into or deposited in this account, including any earnings thereon, shall be owned by me (us jointly), and payment may be made upon my (any of our) request. Upon my death (the death of the last survivor to us), all such funds shall be owned by the P.O. D. payees(s) surviving. Any P.O.D. payee surviving shall have the right to request payment of all or any portion of the funds in the account. Any payment upon my (any of our) request, or the request of any other party with the right to request payment, discharges the credit union from any liability for such payment. I (we) agree that this account and agreement are subject to any and all rules, regulations, bylaws, and policies of the credit union and its board of directors now in effect and as amended or adopted hereafter, and agree to pay any charges or fees which may be required or assessed under such rules, regulations, bylaws, and policies.

We understand that an attorney should be consulted regarding the validity of any person's survivorship rights to any funds in this account, or the fitness of this account or agreement for any particular purpose.

_______________________
Date

Executed By:
P.O.D. Payee(s)

Soc. Sec. No.
Soc. Sec. No.
Executed By:
P.O.D. Payee(s) 		Soc. Sec. No.
Soc. Sec. No.
Executed By:
P.O.D. Payee(s) 		Soc. Sec. No.
Soc. Sec. No.
CONSENT OF SPOUSE

To be completed in Community Property States when Beneficiary is not the spouse.
Instruction: Do not execute this Designation of Beneficiary if you have on file with your credit union a Joint Share Account Agreement which designates the surviving joint tenant as beneficiary of life insurance.

___________________
Date		 ______________________________
Signature of Spouse

Spouse of:

PLEASE SIGN PROXY BELOW
PEORIA BELL CREDIT UNION - Revocable Proxy

The undersigned does hereby constitute and appoint the members of the Board of Directors of Peoria Bell Credit Union, who are the qualified and acting Directors at the time this Proxy is used, as my Proxy and authorize them in my absence at any meeting of the members of Peoria Bell Credit Union to cast any votes I would be entitled to cast if personally present from time to time and from year to year until this Proxy is canceled by written notice delivered to said Credit Union.

___________________
Date		 ______________________________
Signature

Social Security No.