Georgia State University Federal Credit Union

Membership Request

Please provide all of the requested information below. When you have completed the form, print, sign and return the application to:

GSU Federal Credit Union
34 Peachtree St.
Atlanta GA, 30303

USA PATRIOT ACT
Important Information About Procedures For Opening A New Account

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

What this means for you:
When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

Full Name	_______________________________
Address	_______________________________
City	_______________________________	State	_______ Zip _______
Home Phone	______________	Work Phone	______________
* E-Mail Address	_______________________________
* Verify E-Mail Address	_______________________________
Employer	_______________________________
Social Security/TIN	______________	Birth Date	______________
Driver's License Number	______________	State	_______
Lived in GA for the past 5 years? (yes/No)______________ If not, what state? _______
Mother's Maiden Name	_________________________________

If you recevied a statement insert inviting you to join the credit union, please insert the code found on the statement insert here ______________________

You are eligible for membership in Georgia State FCU is you are faculty, staff, students or alumni of Georgia State University. Immediate family members of faculty, staff, students or alumni are also eligble to join. Please choose a box below:

I am a:

Faculty Member of Georgia State University

Immediate family member of a faculty member of Georgia State University

Name of Family Member: _________________________________

Staff Member of Georgia State University

Immediate family member of a staff member of Georgia State University

Name of Family Member: _________________________________

Alumni of Georgia State University

Immediate family member of Georgia State University alumni

Name of Family Member: _________________________________

Georgia State University Student

Immediate family member of Georgia State University student

Name of Family Member: _________________________________

Account/Products Requested:

Savings

Savings Certificates

Checking

Overdraft Protection

Direct Deposit

Payroll Deduction

ATM Services

MasterMoney Check Cards

Money Market

IRA

Visa Credit Cards

Loans

Audio Response

Internet Banking

Other ___________________

Once we have received your application, we will send you an Account Card to complete, sign and return with your $26.00 deposit for your savings account. Please send a copy of your Drivers License or Personal Identification Card with the completed Account Card that you will receive in the mail. If you would like a joint account, please fill out the back of the account card under "Account Ownership" and have the joint member sign under "Authorization" on the front of the Account Card. A copy of a Driver's License or Personal Identification Card is required for joint members.

X___________________________________________

Signature of Depositor. Date

You Must Print, Sign, and Return to Credit Union.