I am applying for the (please check one)

How are you eligible to become a member of Powerco? Help

Primary Applicant
Account Number

Name

Date of Birth

Social Security No. Driver's License No.

Address 1

Address 2

City State Zip

Home Phone No. Work Phone No.

Email Address

Date of Birth

Social Security No. Driver's License No.

Address 1

Address 2

City State Zip

Home Phone No. Work Phone No.

Email Address

Enclosed is a check or money order (must be received before the account can be opened)

Transfer from:

Account No.   Suffix:  

Deposit Amount

Please note: An account information disclosure containing terms and conditions, electronic transfers, funds availability, and Truth-in-Savings will be mailed within 20 calendar days of the date the account is opened.

TIN Certification and Backup Withholding Information
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 correct indentification number and that I am NOT, unless designated below, subject to backup witholding because I have not been notified that I am subject to backup withholding as a result of a failure to report all dividends and interest, or because the IRS has notified me that I am no longer subject to backup withholding, and I am a U.S. person (including a U.S. resident alien).

I am subject to backup withholding        Exempt        I am not a United States citizen or resident (complete W-8 form)

This application is submitted to open an account and/or attain credit. I (We) certify that all information herein is true and complete. I (We) authorize the Credit Union to verify or obtain further information the Credit Union may deem necessary concerning my (our) credit standing. By signing the application, I (We) agree to the terms and disclosures that are included as well as any additional disclosures that are sent to me (us) by the credit union.

____________________________________________________
Primary Owner's Signature

____________________________________________________
Joint Owner's Signature

Click here to reorder checks

Click here for your ATM/Debit Card order form

This form must be printed and completed in its entirety. To print, choose the print option from the file menu or choose the print icon from your shortcut menu. Please sign and return to POWERCO Credit Union via fax or mail:

POWERCO Credit Union, Inc.
Attn: New Accounts
471 Morrison Road, Suite M.
Gahanna, OH 43230
Fax: 614-416-7580

Clicking this button will delete ALL information on the form.