Port Terminal Federal Credit Union Membership Application
Please print this form, fill it out and fax to
713.926.9928
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General Information:
 Will there be a co-applicant on this application? No Yes, 1 co-applicant Yes, 2 co-applicants
 Membership Eligibility:
  Employer  Employer Name:
  Family Member  Family Name:
  Community  Community Name:
 Primary Applicant:
 Last Name:  Middle Name:
 First Name:  Social Security Number (TIN):
 Date of Birth:  Home Phone Number:
 Work Phone Number:  Other Phone Number:
 Email Address:  Mother's Maiden Name
 I certify that:
 The TIN is correct and
 I ( am / am not ) subject to back-up withholding (Circle One) and
 I am a U.S. Person (including a U.S. Resident Alien).
 Drivers License #:  Drivers License State:
 Home Address (not P.O. Box)
 Address 1:
 Address 2:
 City:  State, Zip:
 Time at Current Residence:  Residence Type: Own Rent Other:
 Mailing Address (if different)
 Address 1:
 Address 2:
 City:  State, Zip:
 Employment History
 Present Employer Name:  Employer Phone Number:
 Employer's Address 1:
 Employer's Address 2:
 City:  State, Zip:
 Job Title:  Job Start Date:
 References
 Nearest Relative Not Living With You
 Last Name:  First Name:
 Relationship:  Phone Number:
 Address 1:
 Address 2:
 City:  State, Zip:
 Additional Information
 How would you prefer to be contacted?
  Home Phone
  Work Phone
  Other Phone
  Email Address
  Other:
 Special Instructions/Comments:
 
 
 
 Signature
The Internal Revenue Service does not require your consent to any provision of this contract other than the certifications required to avoid backup withholding.
 Signature:  Date:        

If this is for a joint account
Print this page and then click here for the co-applicant form.