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MCU Ill'J'( kt 011 Ur/ ()IJ Basis for Membership: Account Number: Please tell us about yourself K ChexSystems: Last Name ate of Birth First Name Social Security Number Mothers Maiden Name Middle Name Suffix (Jr. Sr. II) ome one um er BROOKLYN NY City State b ree Address (inducting Apt7ff) ZIP Mailing Address (including Apt. #) City State ZIP FED. BUREAU OF PRISON PO BOX 1043 Employer NY NY 10013 City Employers Address State ZIP Work Phone Number Cell Phone Number Email Address State Drivers Lieens ID 1 Type: ID 2 Type: ID 3 Type: ID 1 Number ID 2 Number ID 3 Number Re-type Email Address (for verification) NY 02/26/13 ID 1 Description ID 1 Expiration Date ID 2 Description ID 3 Description ID 2 Expiration Date ID 3 Expiration Date Joint Account Holder K ChexSystems: Last Name First Name Middle Name Suffix (Jr. Sr. II) Date of Birth Social Security Number Mother's Maiden Name Home Phone Number Street Address (including Apt. #) City State ZIP Mailing Address (including Apt. #) City State ZIP Employer City Employers Address State ZIP Work Phone Number Cell Phone Number Email Address Re-type Email Address (for verification) ID 1 Type: ID 1 Number ID 1 Description ID 1 Expiration Date ID 2 Type: ID 2 Number ID 2 Description ID 2 Expiration Date ID 3 Type: ID 3 Number ID 3 Description ID 3 Expiration Date EFTA00124641 Beneficiary Information (optional) Last Name Name Middle Name Suffix (Jr. Sr. II) Date of Birth Social Security Number Relationship to member BRROKLYN NY Home Phone Number 11214 street Aoaress (including Apt. it) City State ZIP Beneficiary Information (optional) Last Name First Name Middle Name Suffix (Jr. Sr. II) D of Birth Social Security Number Relationship to member Home Phone Number BROOKLYN NY 11214 t. #) City State ZIP Accounts/Services To Open: X Shares X FasTrack Checking Money Martel Touch Tone Teller Date: 09/25/07 ATWCheck Card MCU Online K Alternative Checking K Order Checks I hereby apply for membership and subscribe for at least one share (55.00) in the Municipal Credit Union and agree to conform to its By-Laws and amendments thereof. I agree to be governed by the Account Agreement, Rules and Regulations and Schedule of Dividends, Service Charges and Fees of the Municipal Credit Union applicable to Share, FasTradt Checking, Vacation, Holiday and Money Market accounts as now in effect and as from time to time amended. I agree to be bound by the terms and conditions contained in the MCU Cash Connection, MCU ATM/Check Card and/or Touch Tone Teller Agreements which wil be mailed to me if I elect to receive such service(s). Also, I have received and agree to be band by the forms and conditions of the MCU Online agreement upon my first use of MCU Online service(s). I understand that the designations made on this signature card/form will apply to all MCU deposit accounts which are or will be in the future maintained under the same root account number (except IRA, Youth Club, and Share Certificate accounts), and will have the effect of revoking all previous designations made with regard to such accounts. If a joint tenant has been designated on this signature card, it is agreed that these accounts be payable to either of us and upon the death of one of us, to the survivor. Also. it is agreed that any joint tenant may, without the consent of or notice to the other, pledge all or any part of the shares in these accounts as collateral security for a loan with MCU. If a beneficiary (beneficiaries) has (or have) been designated on this signature card, it is agreed that this is a voluntary and revocable trust, and that upon my/our death, the funds in these accounts, and all other deposit accounts maintained under the same root account number (except IRA, Youth Club, and Share Certificate accounts), will become the property of the named beneficiary or beneficiaries who are alive at the time of my/our death in equal proportions. If both a joint tenant and a beneficiary (or beneficiaries) have been designated on this signature card, it is agreed that the beneliciary(ies) will only acquire an interest in these accounts upon the death of the last surviving joint tenant. By signing below, Irne authorize Municipal Credit Union to perform a credit investigation including the verification of the information on this application. Verification of income and employment may also be required. Under penalties of perjury, I certify (1) that the number shown on this form is my current taxpayer identification number, and (2) that I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of failure to report all interest or dividends, or because the Internal Revenue Service has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. citizen (including a U.S. resident alien). The Internal Revenue Service does not require your consent to any provision of this document other that the certifications required to avoid backup withholding. 09/25/07 Account Holder Signature Date Joint Account Holder Signature Yes, I elect to accept the Check Imaging option and agree to pay the associated service charge. If Joint Account Holder requests an MCU ATM/Check Card, check this box. Manhattan Branch Date ROSANNA TEJEDA Sponsor Account Number Branch Name Member Service Representative EFTA00124642