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Credit Union 1 of Kansas
Membership Application

* Indicates a required field

Membership Eligibility  
I'm eligible for membership because I:




   
Personal Information  
First Name*
Last Name*
Middle Name
Generation
Branch
Address*
Apartment #
City*
State*
Zip*
County:
Phone - Area Code
Phone - Daytime
Phone - Evening
Best Time to Reach You
Email Address *
   
Record Information  
Date of Birth
Gender*
Driver's License State
Mother's Maiden Name
   
Work Information  
Occupation
Employer
Employer Address
Employer City
Employer St
Employer Zip
   
Joint Owner Information  
Complete this section only If you wish to have a joint owner on this account.
Joint: First Name
Joint: Last Name
Joint: Address
Joint: Apartment Number
Joint: City
Joint: ST
Joint: Zip
Joint: Home Phone
Joint: Cell Phone
Joint: Driver's License State
 
Certifications  
Backup Withholding Certification



 
NOT SUBJECT TO WITHHOLDING - By submitting this application, I certify under penalties of perjury that the number shown in the member information on this form is my correct Taxpayer IdentificationNumber (TIN) and I am not subject to withholding either because (a) I have not been notified by the Internal Revenue Service that I am subject to withholding as a result or a failure to report allinterest or dividends or (b) the IRS has notified me that I am no longer subject to backup withholding.
SUBJECT TO WITHHOLDING - I AM subject to withholding due to under reporting and I have not received a notice from the IRS that the backup withholding has terminated.


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NCUA: This credit union is insured by the National Credit Union Administration, a agency of the US government.
Your savings are federally insured to $100,000 by the National Credit Union Administration, an agency of the US government.
We do business in accordance with the Fair Housing Lending law.
We do business in accordance with the Fair Housing Lending law.
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All rights reserved.
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