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Membership Application & Agreement

• Please print this page, and complete the form.
• Have your application notarized.
• Include an initial deposit (min. $5.00).
• Include a copy of a government issued photo ID.
• Mail it to MPS Credit Union (address listed below).

MPS Credit Union
2190 N.W. 72nd Avenue
Miami, FL 33122-1826

Name___________________________________________________________________________
Address_________________________________________________________________________
City______________________________ State_______________ Zip Code___________________
SSN/TIN________________ Phone______________ Beeper___________ Cellular______________
Date of Birth_____________ Driver's License #_____________________ MMN________________
Present Employer (name & address)___________________________________________________
______________________________________________________ Phone____________________
I qualify for membership in this Credit Union because _____________________________________
Relationship__________________________________ a/c #_______________________________

Name____________________________________________________________________________
Address__________________________________________________________________________
City______________________________ State_______________ Zip Code____________________
SSN/TIN________________ Phone______________ Beeper___________ Cellular_______________
Date of Birth_____________ Driver's License #_____________________ MMN_________________

SELECT ONE OWNERSHIP TYPE AND, IF APPLICABLE, INCLUDE A BENEFICIARY
DESIGNATION, THE OWNERSHIP TYPE AND BENEFICIARY DESIGNATION SPECIFIED
ON THIS DOCUMENT WILL REMAIN THE SAME FOR ALL ACCOUNTS
LISTED BELOW.
1. INDIVIDUAL
2. JOINT WITH SURVIVORSHIP (and not as tenants in common)
3. MEMBER AS CUSTODIAN FOR MINOR UNDER THE FLORIDA UNIFORM TRANSFERS TO MINORS ACT (UTMA)
4. TRUST - SEPARATE AGREEMENT DATE ____________________________________________
5. ___________________________________________________________________________
BENEFICIARIES: REVOCABLE TRUST DESIGNATION AS DEFINED IN THE ACCOUNT TERMS AND CONDITIONS:
(Place name and address of beneficiaries below.)
PAY ON DEATH ___________________________________________________________________
_______________________________________________________________________________

BACKUP WITHHOLDING CERTIFICATION

- check box (A) only if true or (B) below:
(A) By signing below, I (name)_____________________________________________
certify under penalties of perjury that (1) the Taxpayer Identification Number (TIN) show 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 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 not longer subject to backup withholding.
(B) A separate W-9 has been completed (or W-8in the case of a non-resident alien).

By singing below, the undersigned agree to the Credit Union by-laws and the terms and conditions of any approved account, as amended from time to time, and authorize the Credit Union to verify credit and employment history by any necessary means, including preparation of a credit report by a credit reporting agency. The undersigned certify that the information provided on this application is true and correct and that the terms on this application apply to all listed accounts. The undersigned acknowledge receipt of a copy of the terms and conditions applicable to each listed account and the following policy discloser:
Fund Availability Truth-In-Savings Electronic Fund Transfers _________________

THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIERED TO AVOID BACKUP WITHHOLDING.

(1) x________________________________________________ ______________________
Member Signature (Date) Member Account #
(2) x________________________________________________ ______________________
Signature (Date) Relationship to Member
(3) x________________________________________________ ______________________
Signature (Date) Relationship to Member

AGENTS THE INDIVIDUAL SIGNING ABOVE ON LINE__________________ IS SIGNING AS:
Power of Attorney - separate agreement on file
A Successor Custodian of a UTMA account
Parent/Guardian
Convenience Account Agent
____________________________________

CHECKS SYSTEMS
*MMN________________________________________________
NEW EXISTING

BOARD/MEMBERSHIP OFFICER________________________________________________

MEMBER SERVICE REPRESENTATIVE__________________________ DATE______________

CUSTOMIZED 1,2,3,4
© 1993 CUPA/Bankers Systems, Inc. St. Cloud, MN (1-800-397-2341) Form MPAA-FL 7/15/96.