Membership

* Indicates Required

• Because Brokaw Credit Union is a not-for-profit financial cooperative, membership is required in order to utilize and enjoy its many financial services and benefits. If eligible, membership is as simple as depositing and maintaining a minimum of $5 in a Primary Savings Account under your name and social security number.

  (Applicants must be 18 years of age or older and must be U.S. citizens to apply online. Minors, resident alients and non-resident aliens may apply by contacting the credit union directly.)

  Application Requirements

  Eligibility

  Are you eligible *

  I live or work in Marathon, Lincoln, Portage, Langlade, Shawano, Waupaca, Clark, Taylor, or Wood Counties in Wisconsin. I am a family member (ie. spouse, parent, child, step parent, step child, grand parent, or grand child of a current Brokaw CU member.) I am an employee of select employee group affiliated with Brokaw CU.

  Name of Family Member *

  How did you hear about us? *

  Friend/Family Newspaper Internet Other Please enter how you heard about us

  By completing this form, you are applying for membership in Brokaw Credit Union, and requesting a Primary Savings Account be opened in your name and social security number (If you are already a member and wish to open other accounts, please go to our online account application.)

  Important Information About 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 ask to see your driver's license or other identifying documents.

  Application Type

  Application Type *

  Individual Account Joint Account

  Account Type

  You may apply for additional account types at this time. All of the terms, conditions, form of account ownership, account selection and other information indicated on this card apply to all of the accounts unless the Credit Union is notified in writing of a change. A minimum deposit may be required for each additional account type opened.

  Additional Accounts

  Secondary Savings Money Market Share Certificate Christmas Club Freedom Checking Regency Checking Advantage Checking

• Applicant Information

  First Name *

  Middle Initial

  Last Name *

  Address *

  City *

  State *

  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Zip *

  Primary Phone *

  Phone Type *

  Home Cell

  Work Phone

  Email *

  Date of Birth *

  Social Security Number *

  Drivers License Number *

  Drivers License State *

  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Mother's Maiden Name *

  Employer *

  Joint Applicant

  Name *

  Address *

  City *

  State *

  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Zip *

  Primary Phone *

  Phone Type *

  Home Cell

  Work Phone *

  Social Security Number *

  Email *

  Date of Birth *

  Drivers License Number *

  Drivers License State *

  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Mother's Maiden Name *

  Employer *

• TIN certification and backup withholding information

  Under penalties of perjury, I certify that: *

  1. The number shown on this form is my correct taxpayer identification number, and
  2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
  3. I am a U.S. citizen.

  If any of these statements is not true of you, please apply directly at the credit union.

• Authorization

  If approved, to complete the account opening process, you must stop by Brokaw Credit Union within 30 days to present your unexpired government-issued photo ID, proof of address (if it is not current on your photo ID) and first deposit.

  * As part of the account opening proccess, Brokaw CU may obtain information about you from a consumer reporting agency. Based on that information, you may or may not be approved to open the account. I authorize Brokaw CU to access consumer reports for me and any joint applicants in order to process this application.

  Applicant authorization date *

  Co-applicant authorization date *

  Additional Information

  For BCU to obtain additional information, if required, how would you prefer to be contacted? *

  Select One Email Phone

  Special Instructions/Comments