Personal Membership Application
Ownership: Personal
Member # (To be provided by the Credit Union)
Self-Help Credit Union, including its divisions may be referred to as "Credit Union."
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 to you: When you open an account, we will ask for your name, address, date of birth
or other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.
Member Name Social Security Number
Second Name Line Mother's Maiden Name
ID Type Number/Value Issued By Expiration Date Date of Birth Gender
Physical Address City State Zip
Mailing Address City State Zip
Other City State Zip
Home Phone Cell Phone Work Phone E-Mail Address
Employer Occupation
Membership Eligibility Requirements - Primary Member Only:
Eligibility Type: ______________________________ Group: ______________________________
* If eligible through The Center for Community Self-Help: The Center for Community Self-Help is a 501(c)(3) nonprofit corporation dedicated
to creating and protecting ownership and economic opportunity for people of color, women, rural residents, and low-wealth families and
communities. Membership in the Center for Community Self-Help requires a $5 fee, which is a tax-deductible contribution.
Additional Information - Primary Member Only:
Providing this additional information is optional. We ask for it because it helps us better understand who our Members are
and how we can better serve them. It also helps us when writing proposals to try and raise money for the Credit Union
and when reporting on the same. The Credit Union does not discriminate on the basis of race, religion, national heritage
ethnic background, gender or sexual preference.
□ I prefer not to answer this information with the Credit Union.
What is your primary racial background? □ American Indian/Alaska Native □ Asian □ Black/African American
□ Native Hawaiian/Other Pacific Islander □ White □ Other (Please Indicate) ____________________
Are you Hispanic/Latino? □ Yes □ No
How many family members are in your household? ____________
What is your approximateDQQXDO household income? ________________
Referral Information - How did you hear about the Credit Union? □ Friend, Family or Co-Worker □ Dissatisfaction □ SRI Search
□ SH Borrower □ SH Loan Borrower □ Ad/Mailer ____________________ □ Article/Publication ____________________
(Please list) (Please list)
□ Business or Professional Referral ____________________ □ Event/Conference ____________________ □ Internet Rate Search ___________________
(Please list) (Please list) (Please list)
□ Other: ____________________
(Please list)
Member Signature Date
FOR OFFICE USE ONLY Branch: Name of MSR:
Member deposits are insured up to $250,000 by the National Credit Union Administration (NCUA).
Personal Membership Application
Help Sheet
Thank you for your interest in a membership with Self-Help Credit Union. Complete each field on the “Personal
Membership Application” as indicated below. If any part of the required information is not received, your
membership will be delayed until all necessary information/items are received. If you have any questions as you
complete this form, please contact us at 1-800-966-7353 or contact one of our branches closest to you.
____________________________________________________________________________________
Ownership
Prefilled as “Personal”
Member Number
This will be assigned by the Credit Union.
Member Information
Complete the Primary Member’s information section as noted below. If a section does not apply to you, please
indicate by N/A.
Member Name* – Enter the name of the primary account owner
Social Security Number* – Enter full social security number or ITIN of the primary account owner
Second Name Line - Leave blank, if not applicable
Mother’s Maiden Name* – Enter primary account owner’s mother’s maiden name
ID Type* – Enter or select ID type for verification. Acceptable types include: Driver’s License, Matricula
Consular, Passport, State Issued ID or Military ID. For any other ID type please type a brief description.
Number/Value – Enter the ID number listed on your ID
Issued By* – Enter the issuing state or agency for the ID
Expiration Date* – Enter expiration date of ID
Date of Birth* – Enter primary account owner’s date of birth – mm/dd/yyyy
Gender – Enter primary account owner’s gender
Physical Address* – Enter primary account owner’s full physical address including city, state and zip (Note:
the physical address must match the address listed on the ID (i.e. driver’s license, state issued ID etc. If not,
proof of address is required)
Mailing Address – Enter a mailing address if different from physical address
Other Address – Leave blank, if not applicable
Home Phone* – Enter home phone number (if a cell phone is used as the home phone list here as well)
Cell Phone – Enter cell phone number, if applicable
Work Phone – Enter work phone number, if applicable
E-mail Address – Enter primary e-mail address, if applicable
Employer* – Enter primary account owner’s current employer (If retired please list last employer)
Occupation* – Enter primary owner’s occupation (If retired please list last occupation e.g. Retired Nurse)
* Required Fields
Member Eligibility Requirements -Primary Member Only:
You can become a member of Self-Help Credit Union if:
a. You live, work, worship or attend school in one of the counties that are listed on the Self-Help’s Website
b. You are a member of an employee/association eligible for membership
c. You are an “immediate family” member of an individual who is a member of the above mentioned eligible
groups. “Members of the immediate family” include the following secondary members: spouse, parent,
and children of the primary members.
d. Or you become a member through The Center for Community Self-Help. Membership in the Center for
Community Self-Help requires a $5 fee, which is a tax-deductible contribution.
Eligibility Type
Select one of the options from drop down list.
If you choose “Geographic” as the eligibility type, in the “Group” field select Live, Work, Worship, or
Attend School, as applicable.
If you choose “Employer/Association” as the eligibility type, in the “Group” field write/type the name
of the employer or the entity. If you join through The Center for Community Self-Help type “Center
for Community Self-Help”.
If you choose “Family” as the eligibility type, in the “Group” field write/type Spouse, Parent, or
Children.
Additional Information – Primary Member Only:
This demographic data is used to assess our effectiveness as a nonprofit organization in serving our communities,
so while this section is optional, we strongly encourage your participation. All information provided by the
applicant is handled in strict accordance with our privacy policy.
Signature & Date
Member signs and dates the application.
