Membership Application

Membership Application Capital Credit Union invites all who reside within a 75-mile radius of Bismarck-Mandan, Fargo, or Hazen, North Dakota or 50-mile radius of Beulah or New Salem, North Dakota to become members
Personal Information
First Name^*:
Middle Name^*:
Last Name^*:
Social Security Number^*:
Date of Birth^*:
Home Phone Number^*:
Cell Phone Number^*:
Email Address^*:
Address (please provide street address, no PO boxes)^*:
City^*:
State^*:
Zip^*:

Joint Owner's Information
First Name:
Middle Name:
Last Name:
Address (please provide street address, no PO boxes):
City:
State:
Zip:
Social Security Number:
Date of Birth:
Home Phone Number:
Relationship to Joint Owner:

Employment Information
Primary Member's Employer:
City:
Phone Number:
Position:
Length:
Joint Owner's Employer:
City:
Phone Number:
Position:
Length:
Please select the service(s) you are interested in:		Savings Checking Loans CDs Mortgage Loans Business Services
Promotional Code:


		I have read and agree to the membership disclosures and the terms and conditions above.^:
Please read and submit to apply for membership: By submitting below, I/we agree to the terms and conditions of the membership and account agreement, truth-in-savings rate and fee schedule, CU Online, Bill Payer and E-Statements disclosures, funds availability policy disclosures, 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 therein. If an ATM card of EFT service or debit card is requested an approved, I/we agree to the terms and acknowledge receipt of the electronic funds transfer agreement. I authorize the credit union to obtain my credit report to determine creditworthiness for credit products offered by Capital Credit Union. Under penalties of perjury, I certify that the Social Security Number (SSN) / taxpayer number I have listed above is my correct number and that I am not subject to backup withholding. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid back up withholding. Please click Submit. A call center representative will contact you.