Membership Application

Membership Type (required)
Will there be a Joint Member on this application?
Primary Member

Joint Member (Optional)

Products and Services
Please select from the list below the products and/or services that you are interested in. * Note: a minimum of $5.00 is required to open and maintain a member share account.

Account Designations
A. If "Joint Member" information is provided above, I wish the following account(s) to be designated as Joint with Survivorship:
B. I would like the following account(s) to be designated as Payable on Death (POD)/Trust Account(s) with Enter Name & Address of Beneficiary as beneficiary:
C. Please designate the owner(s) of the following account(s) as custodian for the minor child under the Uniform Transfers/Gifts to Minors Act (UTTMA/UGMA).

Authorizations and Disclaimers

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 ask to see your driver's license or other identifying documents and make copies of these documents.

By signing below, I certify in accordance with the IRS W-9 instructions provided by the Credit Union and under penalties of perjury, that the Social Security Number (SSN)/Taxpayer Identification Number (TIN) shown is my/the correct identification number and that I am NOT, unless designated below, subject to backup withholding because I have not been notified that I am subject to backup withholding as a result of a failure to report all dividends or interest or because the IRS has notified me that I am no longer subject to backup withholding.

Application Submission

A $5 minimum deposit is required and must be maintained to open a share account.

Thank you for your interest in becoming a member of Lawrence Memorial Credit Union.