CERTIFICATE OF DEPOSIT APPLICATION

MINIMUM BALANCE $250.00

Check one:
TYPE: ( ) NEW CERTIFICATE
( ) Renewal of Certificate maturing on__________________

Term (Place a checkmark next to the desired term):
( ) 3 MO ( ) 6 MO ( ) 9 MO ( ) 12 MO ( ) 15 MO ( ) 18 MO ( ) 21 MO ( ) 24 MO
( ) 36 MO

Divident Payment Method (Select One):
( ) COMPOUNDING….Monthly dividends will accrue and cannot be withdrawn prior to Certificate Maturity.
( ) SIMPLE…….………Monthly dividends will be credited to your Share (savings) Account.

Amount of Certificate: $___________________   _______________%APY

Registered in the following name(s):

________________________	________________________
Share Account #	Member Name
_______/_________/_______	________________________
Social Security Number	Phone Number
________________________	_______/_________/_______
Joint Member	Social Security Number
________________________	_______/_________/_______
Joint Member	Social Security Number
________________________	_______/_________/_______
Beneficiary (POD)	Social Security Number
________________________	_______/_________/_______
Beneficiary (POD)	Social Security Number

Payment Method (Select One):
( ) Please transfer funds from my Share (savings) Account for purchase.
( ) Attached is my check for purchase (check will be deposited in share account to purchase certificate).

Upon Certificate Maturity:
Your certificate will automatically renew continuously at the prevailing annual percentage rate. If at maturity, you wish to cancel your automatic renewal, written authorization must be received no later than 10 calendar days from the date of maturity.

THE UNDERSIGNED ACKNOWLEDGES RECEIPT OF A COPY OF THE TERMS AND CONDITIONS APPLICABLE , AND POLICY DISCLOSURE.

_________________________________________
Member Signature

_________________________________________
Date

* Withdrawal of funds before maturity will result in a penalty equal to 30, 90 or 180 days dividends, depending on the term of the certificate.