Street________________________

City_________________ State____ Zip________

Home Phone Number______________________

Date of Birth_____________________________

Driver's Lic. #__________________________ State Issued_____

Email Address__________________________

Mother's Maiden Name___________________

Place of Employment_____________________

Business Phone_________________________

Employer Address______________________

City______________ State______ Zip_____

Eligibility (choose the appropriate section):

____ I am eligible for membership in AFCU because I work for a member company

Company Name________________________________

Company Address_____________________________

Company Phone_______________________________

____ I am eligible for membership in AFCU because I am a family member of an existing member.

Member's Name________________________________

Member's Signature________________________

Relationship___________________________________

____ I am eligible for membership because I (check one)_____ live, ____work,______workship, _____volunteer, _______ attend school or ____ regularly do business in the city of Newark.

Name and address of qualifying activity checked above:_______________________________________________

____________________________________________________

Ownership Type (check one):

___ Individual  ___ Joint Member  ___ Custodian for minor  ___ Revocable Trust

___ Payable on Death (List Name & Address of Beneficiary Below)

__________________________________________________________

Joint Member Name________________________

Soc Sec No.__________________

Street_______________________________

City____________ State_____ Zip________

Home Phone Number________________________

Date of Birth____________________

Member Signature & Date_______________________________________________

Joint Member Signature & Date__________________________________________

Sign me up for E-Statements! Send my statements electronically to my email address rather than mailing me a paper statement.
Yes____ No____

Send me the Credit Union's FREE periodic Electronic Newsletter that contains fast breaking credit union news and advance notice of special credit union promotions.
Yes____ No____

Account Number___________________

Soc Sec No_____________________

Name_____________________________

Date of Birth____________________

Driver's Lic. #_________________________

State Issued__________________________

Joint Member Name (if desired)____________________________________

Soc Sec No.________________________________

Street_____________________________________

Phone__________________

City________________________ State______ Zip_______

Member Signature & Date____________________________________________

Joint Member Signature & Date____________________________________________

Account Number__________________________

Member Name____________________________

Phone No._______________________

Joint Member Name_______________________

Mother's Maiden Name_______________

Address __________________________

City____________ State____ Zip________

Do you want a card in joint owner's name?  _____yes  _____no

To apply for an Atlantic FCU VISA®Check Card, you must have an Atlantic Federal CU Checking Account. If you would like 24-hour ATM Access and do not have an Atlantic Federal CU Checking Account, your application will be processed for an Atlantic Federal CU ATM Card.

Member Signature & Date__________________________________________________

Joint Member Signature & Date____________________________________________