Electric Cooperatives FCU Checking/Savings Account Application
Please print this form, fill it out and fax to 501-570-2393
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 Account Information
 Will there be a co-applicant on this application?    Yes    No
 I am interested in:
    Checking Account
        Type of Checking Account:  ____________________________________________
        Initial Deposit Amount:  $_______________________________________________
        Source of Deposit:
           Transfer from a current account.   Account Number:  _____________________

           I will transfer funds from another institution.

           I will mail a check/money order.

           Other.   (please describe)  _________________________________________
    Savings Account
        Type of Savings Account:  _____________________________________________
        Initial Deposit Amount:  $_______________________________________________
        Source of Deposit:
           Transfer from a current account.   Account Number:  _____________________

           I will transfer funds from another institution.

           I will mail a check/money order.

           Other.   (please describe)  _________________________________________

    Other Account
        Description:  ________________________________________________________
        Initial Deposit Amount:  $_______________________________________________
        Source of Deposit:
           Transfer from a current account.   Account Number:  _____________________

           I will transfer funds from another institution.

           I will mail a check/money order.

           Other.   (please describe)  _________________________________________
 I am also interested in:
    ATM Card

    ATM and Check/Debit Card

    Credit Card

    Direct Deposit

    Other   (please describe)  ______________________________________________
 Primary Applicant
 Last Name:  Member Number:
 First Name:  Middle Name:
 Social Security Number (TIN):  Date of Birth:
 Home Phone Number:  Work Phone Number:
 Other Phone Number:  Email Address:
 Drivers License #:  Drivers License State:
 Mother's Maiden Name:  Present Employer Name:
 Home Address
 Address 1: 
 Address 2: 
 City:  State, Zip:
 Co-Applicant
 Last Name:  Member Number:
 First Name:  Middle Name:
 Social Security Number (TIN):  Date of Birth:
 Home Phone Number:  Work Phone Number:
 Other Phone Number:  Email Address:
 Drivers License #:  Drivers License State:
 Mother's Maiden Name:  Present Employer Name:
 Home Address
 Address 1: 
 Address 2: 
 City:  State, Zip:
 Additional Information
 How would you prefer to be contacted?
  Home Phone

  Work Phone

  Other Phone

  Email Address

  Other:
 Special Instructions/Comments:
 
 
 
 Signatures
 Primary Applicant Signature:  Date:        
 Co-Applicant Signature:  Date: