Membership Application

Membership Eligibility (Check One)
Employer- Name:
Family Member- Name:
Community- City:
Donation- Boys & Girls Club
or With Hope Foundation:
Account Information
Is there a joint-owner on this application? Yes No
I am interested in (please check only one):
Checking Account
Savings Account
Share Certificate Account
IRA Certificate Account
Initial Deposit Amount:
Source of Deposit: Transfer from Another Institution

Mail a Check or Money Order
Other
Primary Applicant Information
Full Name
Address

(no P.O. boxes)
City
State
Zip
Mailing Address

(if different)
City
State
Zip
Email Address
Home Phone
Cell Phone
Business Phone
Social Sec. No.
I certify that (check all that apply): I am subject to backup withholding

I am not subject to backup withholding

I am a US Citizen

My SSN/TIN is correct
Driver License Number
Driver License State
Date of Birth
Mother’s Maiden Name
Employer
Joint Member Information (if applicable, otherwise skip this section)
Full Name
Address

(no P.O. boxes)
City
State
Zip
Mailing Address

(if different)
City
State
Zip
Email Address
Home Phone
Cell Phone
Business Phone
Social Sec. No.
I certify that (check all that apply): I am subject to backup withholding

I am not subject to backup withholding

I am a US Person

My SSN/TIN is correct
Driver License Number
Driver License State
Date of Birth
Mother’s Maiden Name
Employer
How Would You Prefer to be Contacted Home Phone Work Phone
Email Other
Comments or Questions