Membership App

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Membership Eligibility

How do you qualify for membership?*

I'm a current employee of a VA Medical Center I am a regularly scheduled volunteer of a VA Medical Center I am a retired VA Medical Center employee I have a family member that is a current Member of VA Desert Pacific FCU I will be donating $20 annually to the Desert Pacific Foundation

VA Medical Center location*

Which location?*

What is the name of the existing member?*

What is their relationship to you?*

Personal Information

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 You for Your name, address, date of birth, and other information that will allow Us to identify You. We may also ask to see Your driver' s license or other identifying documents.

Name*

First Name

Middle Name (optional)

Last Name

SSN*

Date of Birth*

Mother's Maiden Name*

Identification

Please select a form of identification to upload*

Please upload here*

No File Chosen

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Physical Address and Contact Information

Physical/Residential Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Please note: a utility bill and/or bank statement MAY be required if we are unable to validate your address. This typically occurs if you recently relocated within the last 2-3 months and haven't done too much business using the updated address. If this happens, we'll be in contact with you and leave your membership application pending until we receive additional documentation.

Is this also your mailing address?*

Yes No

Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Cell Phone*

Work Phone

Home Phone

Email*

Taxpayer Identification and Backup Withholding

Under penalties of perjury, You certify: (1) that the number shown on this form is Your correct taxpayer identification number (or the minor beneficiary' s correct taxpayer identification number if the Account is established under the Uniform Gift/Transfer to Minors Act); (2) that You are not subject to backup withholding either because You have not been notified that You are subject to backup withholding as result of a failure to report all interest dividends, or the Internal Revenue Service (IRS) has notified You that You are no longer subject to backup withholding; (3) that unless You have indicated to the contrary, You are a U.S. person (including a U.S. resident alien); and (4) You are exempt from FATCA reporting.

INSTRUCTION TO SIGNER. If You have been notified by the Internal Revenue Service (IRS) that You are subject to backup withholding due to payee underreporting and You have not received a notice from the IRS that the backup withholding has terminated, You must check the appropriate box below. *

You are exempt from withholding You are subject to backup withholding You are a foreign person and not a U.S. resident alien None of the above

Employment and Income

Is your employer's address 5901 E. 7th Street, Long Beach, CA 90822?*

Yes No

Is your employer's address 11301 Wilshire Blvd, Los Angeles, CA 90073?*

Yes No

Is your employer's address 11201 Benton St, Loma Linda, CA 92357?*

Yes No

Is your employer's address 6900 N. Pecos Rd, North Las Vegas, NV 89086?*

Yes No

Employment Status*

Employer Name*

Occupation*

Employer/Business Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Gross Monthly Income (Before taxes)* $

Start Date*

Please provide your most recent paystub or job offer letter here:*

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File uploads may not work on some mobile devices.

Optional Joint and Beneficiary Info

Would you like to add a Joint owner to your membership?*

No Yes

Joint Name*

First Name

Middle Name (optional)

Last Name

Joint E-mail Address*

Would you like to add one or more beneficiaries to your membership?*

No Yes

How many beneficiaries will you be adding?*

1 beneficiary (100% of funds) 2 beneficiaries (50% of funds each) 3 beneficiaries (33% of funds each) 4 beneficiaries (25% of funds each)

Beneficiary 1: Name*

First Name

Middle Name (optional)

Last Name

Beneficiary 1: Date of Birth*

Beneficiary 1: Phone

Beneficiary 1: Email

Beneficiary 2: Name*

First Name

Middle Name (optional)

Last Name

Beneficiary 2: Date of Birth*

Beneficiary 2: Phone

Beneficiary 2: Email

Beneficiary 3: Name*

First Name

Middle Name (optional)

Last Name

Beneficiary 3: Date of Birth*

Beneficiary 3: Phone

Beneficiary 3: Email

Beneficiary 4: Name*

First Name

Middle Name (optional)

Last Name

Beneficiary 4: Date of Birth*

Beneficiary 4: Phone

Beneficiary 4: Email

Experience

How did you hear about us?*

New Employee Orientation Saw your branch at a VA Medical Center Referred by an existing member

Other:

What is your primary goal for establishing membership with us?*

I'm mostly looking for a place to save some money. I want to take advantage of your lower rates on loans. I plan on making you my primary financial institution.

Please let us know who we have to thank for referring you:*

First Name

Middle Name (optional)

Last Name

Disclosures and Signature

Fee Schedule

Truth in Savings Disclosure

Electronic Fund Transfer & Disclosure Agreement

How Your Account is Insured

You hereby apply for membership with VA Desert Pacific Federal Credit Union. You warrant the truth of the information contained in Your application for membership and/or in subsequent representations to Us. You realize that such information will be relied upon by Us in determining Your membership eligibility. You hereby authorize Us, Our employees and agents to investigate and verify any information provided to Us by You, including Our obtaining a consumer credit report. By signing below, You agree to be bound by the terms and conditions found within Your application for membership and to the bylaws, rules and regulations of VA Desert Pacific Federal Credit Union in effect from time to time. You further acknowledge receiving a copy of the Agreements and Disclosures related to Your Account(s) and You agree to be bound by the terms and conditions found therein. If Your application for membership is a joint application, any liability created by the use of Your Account is joint and several. You authorize any person, association, firm, corporation or personnel office to furnish information concerning Your affairs upon Our request, including, but not limited to, providing credit and employment history information. In addition to establishing a primary Share Account, You may also from time to time request additional Accounts and/or Account Services be established on Your behalf and/or the addition of joint owner(s) of Your Account(s). Your signature below is Your continuing authorization for VA Desert Pacific Federal Credit Union to follow Your written or verbal instructions to do so and You agree that Your continuing authorization will remain in effect unless We receive written instructions to the contrary. You hereby authorize Us to recognize any of the signatures subscribed herein in the payment of funds or the transaction of any business for Your Account(s).

The Internal Revenue Service does not require Your consent to any provision of this document other than the certifications required to avoid backup withholding.

I have read and acknowledge receipt of the Fee Schedule*

No Yes

I have read and acknowledge receipt of the Truth in Savings Disclosure*

No Yes

I have read and acknowledge receipt of the Electronic Fund Transfer & Disclosure Agreement*

No Yes

I have read and acknowledge receipt of the How Your Account is Insured brochure*

No Yes

In order for Us to open Your membership, We ask that You deposit the minimum required balance of $50 to Your Savings account. Please note that the $50 remains on hold in Your account until such time as You choose to close Your membership.

By providing us your information, you are authorizing VA Desert Pacific FCU to perform a one-time debit to the card in the amount of $50.00. This amount will be credited to your VA Desert Pacific FCU account ending in S0000 at the time your account is opened. If we are unable to open your membership, we will credit back your funds using the information provided. Additionally, you acknowledge that you are the owner of the account provided and/or authorized to perform transactions from the card.

Please provide your Visa or Mastercard information below:*

Membership deposit amount $

Quantity

Signature*

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