Membership Form

Member Information

First Name *
Last Name *
• Street Address *
City *
State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC
Zip Code *
Date of Birth *
SSN/TIN *
Photo Identification *
Driver's License # State ID # Passport
We will need an updated copy of your photo ID (i.e. driver's license, state ID, passport). Please upload as an image file. *
Expiration Date *
Phone Number *
Phone Type Mobile Work Home
Email Address *
• I qualify for membership in this credit union because *
  Please Select an Option I live, work, attend school or worship in DeKalb county I live, work, attend school or worship in Lee county I live, work, attend school or worship in Ogle county Immediate family member of an NIFCU member Member of the same household as an NIFCU member

  Family Member's Information

  First Name *
  Last Name *
  • Street Address *
  City *
  State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC
  Zip Code *

  Household Member's Information

  First Name *
  Last Name *
  • Street Address *
  City *
  State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC
  Zip Code *

• How did you hear about us?

Account Information

• Type of Account *
  Savings Only Savings and Checking
• Account Ownership *
  Individual Joint with survivorship Trust-separate agreement dated: Account Owner Date
• Beneficiary Designation *
  Beneficiaries
Please list the names and addresses of beneficiaries *

Joint Owner Information

First Name *

Last Name *

Street Address *

City *

State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC

Zip Code *

Date of Birth *

SSN/TIN *

Photo Identification *

Driver's License # State ID # Passport

We will need a dated copy of the joint owner's current address (i.e. utility bill, account statement, lease, etc.) Please upload as an image file. *

Expiration Date *

Phone Number *

Phone Type Mobile Work Home

Email Address *
• Backup withholding Certification *
  By submitting this form, I certify under penalties of perjury that (1) the Taxpayer Identification Number (TIN) showing above is my correct TIN and I am not subject to backup withholding either because (a) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends or (b) the IRS has notified me that I am no longer subject to backup withholding and (2) I am a U.S. person (including a U.S. resident alien).
  A separation certification has been completed.
• Signature *
  Clear Signature
• Joint Applicant Signature *
  Clear Signature