Membership/Loan Application 

FOR A MEMBERSHIP APPLICATION: 

Only the areas highlighted in yellow are required. 

What Makes Us Unique? 

FOR A LOAN APPLICATION:

Please complete all appropriate sections 

including Primary Member / Loan Applicant. 

ALL APPLICATIONS MUST BE SIGNED. 

Please return this ENTIRE application along 

with the required copies of identification, and 

the appropriate check or money order, to the 

Credit Union. 

Our Personalized Service. 
Without it, we would be just 
another financial institution. 

www.ibmsecu.org  •  serviceplus@ibmsecu.org 
800.873.5100  •  561.982.4700 

*In  accordance  with  the  USA  PATRIOT  Act,  all  financial  institutions  are  required  to  obtain,  verify, 
record and retain the information that identifies each person who opens a new Membership account, 
to help the government fight the funding of terrorism and money laundering activities. Federal law 
requires your legal name, tax identification number, residential and mailing addresses, date of birth, 
Driver’s License photocopies and/or other identifying documents, and any other information that will 
allow us to identify you and any joint signers. In addition, the identification and information that you, 
and any joint signer(s), have provided will be verified by reports obtained from credit bureaus and
other financial reporting agencies, as part of our Membership qualification process. 

A1132  3/09 

It’s Time 
We Get To Know 
Each Other 

You and your family members now have the financial 
opportunity of a lifetime that will last a lifetime, 
even if you move or change jobs. 

Joining is easy. All that is required is a $5 deposit 
to establish a Membership savings account and $25 to 
establish a checking account. Once you have joined, you 
may open additional accounts by logging on to Online 
Banking at www.ibmsecu.org. 

All share accounts are federally insured up to $250,000 
by the National Credit Union Administration (NCUA). 

Build A Long-Term  Financial Relationship 

It’s easy to apply 

1 Fill out the application on the reverse side. For a 

Membership, only the sections highlighted in yellow 
are required. 

2 Include a copy of one form of unexpired 

government-issued photo identification such as a 
Driver’s License, State ID, U.S. Passport, Military ID 
or Resident Alien Card. 
Please note that if the address shown on the ID does not match your 
current address, we will require additional identification in the form 
of a residential utility bill. 

3 Include a copy of one form of unexpired 
government-issued photo identification 
(same as above) for any joint signers. 

4 Include the appropriate check or money order: 
$5 to open a Membership (savings) account; or
$30 to open a Membership and checking account. 

Please sign, date, and return the completed application, 
copies of identification and your check or money order to: 
IBM Southeast EFCU, P.O. Box 5090, Boca Raton, FL 
33431-0890. Contact Member Services at 800.873.5100, 
561.982.4700 or serviceplus@ibmsecu.org. 

Membership/Loan Application 

For a Membership Application only the areas highlighted in yellow are required. For a Loan Application please complete all appropriate sections 
INCLUDING Primary Member/ Loan Applicant. ALL APPLICATIONS MUST BE SIGNED and this entire application should be returned to the Credit Union. 

MEMBER # 
(IF APPLICABLE) 

TYPE OF MEMBERSHIP REQUESTED  (Check Applicable) 

CHOOSE THE PIN NUMBER FOR YOUR CARD 

JOINT SIGNER  (If Applicable)  To add additional joint signers, contact the Credit Union. 

READ CAREFULLY AND SIGN  (Required) 

✔
❏ Membership (savings account required with $5 minimum deposit) 
❏ FREE Checking ($25 minimum deposit) 
❏ Additional Account 
❏ Account Change ______________________________________ 
❏ I’m interested in receiving eStatements (electronic statements), 

instead of paper statements. 

❏ I will also sign up for eMessenger at www.ibmsecu.org. 
I understand that my email address will not be shared with 
non-affiliated sources, and I may cancel this service at any time. 

1.  Call TELEPIN at 800.224.7670, and enter 50041. 

(the “client code” for IBM Southeast EFCU) 

2.  Follow the automated instructions to choose your PIN. 

3.  Fill in your order # here 

(this is not your PIN). 

4.  Continue to follow automated instructions to choose your PIN. 
❏ For an additional card and PIN for your Joint Signer, please have 
them follow the TELEPIN instructions above, and enter their order 
number here 

(this is not your PIN). 

To use TELEPIN you must be at least 18 years old. Please return within 10 days for processing and qualification. If you 
need assistance, please call 800.873.5100,ext.4791, or 561.982.4700,ext. 4791. We will process your request as soon as we 
receive your application with your unique six-digit “transaction order number” on it. Otherwise, a card cannot be issued. 

TYPE OF LOAN  REQUESTED  (Check If Applicable) 
To apply for credit, please include a copy of a current pay stub for you and any coapplicants as verification of income. 
❏ NEW CAR LOAN  ❏ USED CAR LOAN  ❏ VISA CLASSIC  ❏ VISA PLATINUM 

❏ OTHER __________________________________________________ 

AMOUNT/LIMIT ____________________________________________  TERM ______________________________ 

Application Must Be Signed On Right Panel. 

PRIMARY MEMBER # 
(IF ALREADY A MEMBER)

PRIMARY MEMBER / LOAN APPLICANT  (Required For ALL Applications) 

FIRST NAME 

MIDDLE INITIAL 

LAST NAME 

RELATIONSHIP 

SOCIAL SECURITY # 

DATE OF BIRTH 

ADDRESS ( ❏ CHECK IF DIFFERENT FROM PRIMARY MEMBER / APPLICANT ) 

CITY 

STATE 

ZIP CODE 

BUSINESS PHONE 

EXT. 

HOME PHONE 

EMAIL ADDRESS 

PASSWORD (for security purposes)* 

DRIVER’S LICENSE # 

OCCUPATION 

EMPLOYER 

GROSS MONTHLY INCOME $ 

OTHER INCOME $ 

HOUSING COST:  $/mo. 

TIME AT RESIDENCE (YRS./MOS.) 

❏ MALE  ❏ FEMALE 

STATE 

DATE HIRED 

❏ RENT  ❏ OWN 

NEAREST RELATIVE’S NAME (NOT LIVING WITH YOU) 

RELATIONSHIP 

PHONE 

ADDRESS 

CITY 

STATE 

ZIP CODE 

*Password required for telephone or e-mail identification purposes; example: favorite sports team, pet name, etc. (Note: this is not your online password/PIN) 

BENEFICIARY  (Optional)  To add additional beneficiaries, contact the Credit Union. 

SOCIAL SECURITY # 

DATE OF BIRTH 

RELATIONSHIP 

FIRST NAME 

MIDDLE INITIAL 

LAST NAME 

PHONE 

FIRST NAME 

SOCIAL SECURITY # 

RESIDENTIAL ADDRESS REQUIRED (NO POST OFFICE BOXES) 

MAILING ADDRESS (IF DIFFERENT FROM ABOVE) 

MIDDLE INITIAL 

LAST NAME 

ADDRESS ( ❏ CHECK IF ADDRESS IS SAME AS ABOVE ) 

CITY 

STATE 

ZIP CODE 

DATE OF BIRTH 

CITY 

CITY 

STATE 

STATE 

❏ MALE  ❏ FEMALE 

ZIP CODE 

ZIP CODE 

REFER A FAMILY MEMBER TODAY!  (Optional) 

BUSINESS PHONE 

EXT. 

HOME PHONE 

EMAIL ADDRESS 

NAME OF QUALIFYING EMPLOYER / ORGANIZATION OR FAMILY / HOUSEHOLD MEMBER 

FIRST NAME 

ADDRESS 

LAST NAME 

HOME PHONE 

E-MAIL ADDRESS 

CITY 

STATE 

ZIP CODE 

PASSWORD (for security purposes)* 

DRIVER’S LICENSE # 

STATE 

OCCUPATION 

EMPLOYER 

GROSS MONTHLY INCOME $ 

DATE HIRED 

FOR CREDIT UNION USE ONLY 

OTHER INCOME $ 

HOUSING COST:  $/mo. 

TIME AT RESIDENCE (YRS./MOS.) 

NEAREST RELATIVE’S NAME (NOT LIVING WITH YOU) 

RELATIONSHIP 

ADDRESS 

CITY 

PHONE 

STATE 

❏ RENT  ❏ OWN 

ZIP CODE 

*Password required for telephone or e-mail identification purposes; example: favorite sports team, pet name, etc. (Note: this is not your online password/PIN) 

Staff OP # 

Verifier OP # 

MICR # 

Member # 

Acct. Type: 

ChexSystems SS# issue date:  Member: 

Form of identification viewed for: Member: 
Checks Ordered:  ❏ Yes  ❏ No  ❏ N/A 
VR: ❏ Yes  ❏ No  ❏ N/A 

Joint owner: 

Joint owner: 

ChexSystems Record: 

ChexSystems Record: 

VISA Check Card:  ❏ Yes  ❏ No  ❏ N/A 

HB: ❏ Yes  ❏ No  ❏ N/A 

eStatements: ❏ Yes  ❏ No 

____ /____ /____ Date Opened  [  ] In Person 

[  ] By Mail 

[  ] Fax 

[  ] SEG 

[  ] Online Banking 

The information on this application is given for the purpose of establishing Membership and 
obtaining/updating  credit.  By  signing,  I,  and  any  Joint  Signers,  certify  under  penalties  of 
perjury that: I am within the field of Membership of this Credit Union; the information provided 
on  this  application  is  true  and  correct;  and  my  signature  on  this  application  applies  to  all 
accounts under my name at this Credit Union. This signature allows the Credit Union to use a 
facsimile  signature  on  future  applications.  This  signature  also  authorizes  the  issuance  of  a 
VISA Check Card with certain qualifications, and the Personal Identification Numbers (PINs) 
used to access the Telephone and Online Banking systems. Using my Membership Number 
and  (PIN)  to  access  Telephone  Banking  and/or  Online  Banking  will  also  be  considered  my 
authorized  signature,  to  process  certain  transactions  and  account  maintenance,  including 
additional  account  openings.  I  understand  that  I  am  responsible  for  protecting  the 
confidentiality of my PINs, and that I may be held liable for any unauthorized transactions if it 
is determined that my negligence or other actions contributed to any fraudulent activity. I also 
agree to be bound to the terms and conditions of any account that I have in the Credit Union 
now  or  in  the  future.  I  authorize  the  Credit  Union  to  obtain  information  from  any  source 
concerning  statements  made  herein.  If  this  application  is  accepted,  I  promise  to  pay  all 
charges  incurred  and  agree  to  be  bound  by  the  terms  and  conditions  of  the  applicable 
Membership and loan disclosures, and/or credit card agreements, which I have received and 
retained. I understand and acknowledge that the collateral also secures any other obligations 
that I may now or in the future have with IBM Southeast EFCU and fees and costs charged 
against  our  account(s).  Statutory  lien:  If  I  am  in  default  on  a  financial  obligation  to  IBM 
Southeast EFCU, federal law gives the Credit Union the right to apply the balance of shares and 
dividends in my account(s) at the time of default to satisfy that obligation. Once I am in default, 
IBM Southeast EFCU may exercise this right without further notice to me. Credit is subject to 
approval. For full details on the rates, terms, fees, penalties and conditions, that may apply to 
my account(s) I will refer to a current: Share Account Rate Sheet, Membership Disclosure, Fee 
Schedule,  Loan  Rate  Sheet  and  Loan  Disclosure.  By  signing  below  I  agree  to  receive 
information  on  Credit  Union,  and  non-affiliated  third-party  products,  services  and  special 
offers at the email and/or mailing addresses I’ve listed. Your address(es) will not be shared 
with other non-affiliated sources, and you may opt-out of this service at any time. Credit Union 
Membership  and  all  products  and  services  are  provided  with  Credit  Union  acceptance  and 
approval, and may be suspended or revoked at the Credit Union's discretion. In accordance 
with Reg. V and the F.A.C.T. Act, we may provide negative information about you and any joint 
signers, co-borrowers or guarantors regarding an insolvency, negative balance, NSF history, 
delinquency, overlimit late payment or default on any and all of your account(s) to be included 
in your credit report and financial records. 

By signing, I, and any Joint Signers, certify under penalties of perjury that (1) the Taxpayer 
Identification Number (TIN) shown on this form is my correct TIN and I am a U.S. person or 
resident alien, 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 no longer subject 
to  backup  withholding.  The  Internal  Revenue  Service  does  not  require  my  consent  to  any 
provision of this document other than the certifications required to avoid backup withholding. 

Notice  to  Members  residing  in  Community  Property  States – Arizona  (AZ),  California  (CA), 
Idaho (ID), Louisiana (LA), New Mexico (NM), Nevada (NV), Puerto Rico (PR), Texas (TX), 
Wisconsin  (WI),  Washington  (WA):  When  applying  for  secured  or  unsecured  credit  where 
both parties’ incomes are being considered as a basis for repayment for loan approval, the 
Credit Union requires a Joint Loan Application signed by both parties as Member/Borrower 
and Joint Signer/Co-Borrower, with the debt of both parties disclosed. A current credit report 
will be obtained on both parties to verify debt, and verification of income is required. 

Information about the party making payments is also required if you are relying on alimony 
and/or child support as a basis for repayment on an Individual Loan Application. A current 
credit report and verification of income is required. 

1 form of unexpired government-issued photo ID must be 
presented at time of application for each Member and 
Joint Signer. 
The minimum deposit is $5 for Membership (savings) account, 
and $30 for Membership (savings) and checking account. 

SIGNATURE OF MEMBER 

JOINT SIGNATURE 

DATE 

DATE 

❏ I DO NOT AGREE TO ACCEPT JOINT CREDIT LOAN OBLIGATIONS. 
❏ I AGREE TO JOINT OBLIGATION SAVINGS INSTRUMENTS ONLY.