Patriot Equity Credit Union (PECU) Membership Application Page

To use this form:
Complete the form on screen, print and fax, mail, or bring to any of our two convenient locations. If mailed or faxed, please send a copy of your driver's license and social security card along with your application and check.

Account Type
	Share/Savings	Money Market
	Share Draft/Checking	Other
	Share Certificate/Certificate	Other

Member Application and Ownership Information
Account No.
Member
Street
City/State/Zip
Home Phone
Work Phone
Employment
SSN No.
Driver's Lic. No.
Date of Birth
Mother's Maiden Name
Eligibility for Membership

Account Services
	Payroll Deduction/Direct Deposit	ATM Card
	Overdraft Protection (indicate transfer priority below)	Debit Card
		Other EFT Service
	Other	Other

Account Ownership
Designate the ownership of the accounts and responsibility for the services requested.
		Single Party
		Multiple Party with Survivorship
		Multiple Party without Survivorship

Joint Owner One
Street
City/State/Zip
Home Phone
Work Phone
SSN No.
Driver's Lic. No.
Date of Birth
Mother's Maiden Name

Joint Owner Two
Street
City/State/Zip
Home Phone
Work Phone
SSN No.
Driver's Lic. No.
Date of Birth
Mother's Maiden Name

X_________________________________
Primary Signature and Date

X_________________________________
Joint Owner 1 Signature and Date

X_________________________________
Joint Owner 2 Signature and Date

After completing the form on screen, print out and fax, mail, or bring to either office. If mailed or faxed, please send a copy of your driver's license and social security card along with your application and check.