GA Power NE Credit Union
285 Newton Bridge Road
Athens GA, 30607
Fax: (706) 559-9602		 ACCOUNT CARD
ACCOUNT TYPE
All of the terms, conditions, form of account ownership, account selection and othe information indicated on this card apply to all of the accounts listed below unless the credit union is notified in writing of a change.
SUFFIX* SUFFIX*
Share/Savings Money Market
Share Draft/Checking Living Trust
Share Certificate Other
* The Account number for each of the accounts listed above consists of the suffix added to the end of the Member Number listed below. If this card applies to more than one account of the same type, more than one suffix will be listed for that account type.
MEMBER APPLICATION AND OWNERSHIP INFORMATION
Member/Owner
 Member No.
Street SSN/TIN
City/State/Zip Driver's Lic. No.
Home Phone Date of Birth
Listed Unlisted Security Code
Work Phone Employment
E-mail    
Eligibility for Membership    
TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION
Under penalties of perjury, I certify that:
(1) The number shown on this form is my correct taxpayer identification number,
(2) I am not subject to backup withholding because:(a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
(3) I am a U.S. person (including a U.S. resident alien).
Certification Instructions. Uncheck item 2 above if you have been notified by the IRS that you are currently subject to backup witholding becuse you have failed to report all intrest and dividends on you tax return. Uncheck item 3 and complete a W-8 BEN if you are not a U.S. person
AUTHORIZATION

By Signing below, I/we agree to the terms and conditions of the Membership and Account Agreement, Truth-in-Savings Rate and Fee Schedule, Funds Availability Policy Disclosure, if applicable, and to any amendment the Credit Union makes from time to time which are incorporated herein. I/We acknowledge receipt of a copy of the Agreement and Disclosures applicable to the accounts and services requested herein. If an access card or EFT services is requested and provided, I/We agree to the terms of and acknowledge receipt of the Electronic Funds Transfer Agreement. The Internal Revenue Service dose not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

X_ ___________________________________________ X_ ___________________________________________
Signature Date Signature Date
X_ ___________________________________________ X_ ___________________________________________
Signature Date Signature Date
ACCOUNT SERVICES
Payroll Deduction/Direct Deposit ATM Card
Overdraft Protection (Indicate transfer priority below) Debit Card
Audio Response
PC Access/Internet Banking Other
ACCOUNT OWNERSHIP
Designate the ownership of the accounts and responsibility for the services requested
Individual Joint Account with Survivorship Joint Account without Survivorship
Joint Owner SSN/TIN
Street Driver's Lic. No.
City/State/Zip Date of Birth
Home Phone Security Code
Listed Unlisted E-mail
Work Phone    
 
Joint Owner SSN/TIN
Street Driver's Lic. No.
City/State/Zip Date of Birth
Home Phone Security Code
Listed Unlisted E-mail
Work Phone    
ACCOUNT DESIGNATIONS
Payable on Death (POD)/Trust Account All Accounts
Designate specific account(s)
Beneficiary/POD Payee Beneficiary/POD Payee
Street Street
City/State/Zip City/State/Zip
Agency Print name of Agent
All Accounts Designate specific account(s)
UTTMA/UGMA (as custodian for (minor) under the Uniform Transfer/Gifts to Minors Act)
Minor's TIN/SSN
Other See Account Authorization Card
* PERMANENT CARD WILL BE COMPLETED BY THE CREDIT UNION UPON RECEIPT
AND SENT TO YOU FOR FINAL SIGNATURE.
You Must Print, Sign, and Return to Credit Union
(by mail, fax or in person)
A signature is needed to complete the process