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Central Vermont Medical Center, Inc. Credit Union
Universal Membership Application

Applicants are required to provide all the requested information for the member/owner prior to sending this membership application form. You acknowledge that sending this application for membership is only a notification to the Credit Union of your intention to become a member. All potential members are required by Federal Law (see important information below) to personally appear at the Credit Union prior to becoming a member, and opening an account. Members are required to open and maintain a regular share account with a minimum balance of $25.00.

Regular Share (Savings)

Member/Owner

Member/Owner (Name):
Social Security Number: Driver’s License:
Date of Birth:
Street:
City:
State: Zip:
Home Phone:
Work Phone:
Employer:
Email Address:
Eligibility for Membership:

Joint Account Owner (if applicable)

Joint Owner of Account (Name):
Social Security Number: Driver’s License:
Date of Birth:
Street:
City:
State: Zip:
Home Phone:
Work Phone:
Employer:
Email Address:
Eligibility for Membership:
Authorization Notice: By submitting this application to the Credit Union, you certify that everything you have stated in this application is correct to the best of your knowledge, and you have read the eligibility requirements for the Credit Union. You understand that the Credit Union will rely on the representations you make in this application when deciding whether to grant membership. You agree to immediately notify us of changes to any of the information you have provided in this application. You understand that it is a federal crime to willfully and deliberately provide incomplete or incorrect information on applications made to Credit Unions or State Chartered Credit Unions insured by NCUA.

IMPORTANT INFORMATION: USA PATRIOT ACT PROCEDURES FOR OPENING A NEW ACCOUNT 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 also ask to see your driver’s license and may ask for other identifying documents.

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