Secure New Account Application

	Existing Members: Use this secure form to open a new account. To add services to an existing account, please select the appropriate item below and complete all request information on the New Account Application. When complete, please press SUBMIT. To complete the account opening process, please print this completed form, sign and date it and mail it to us with your opening deposit of $5.00 or more. All fields with an asterisk (*) indicated required fields that must be completed before submitting your application.
*	Type of Account
	Individual Account
	Joint Account

	I would like to open the following account:
	The minimum opening deposit for all Share Savings and Checking Accounts is $5.00. For all other products, please see below.
	FREE Checking
	Dividend Checking
	Term Certificate (minimum opening deposit $500.00)	Term

	Statement Savings (ATM, Tele-Touch and Electronic Access available)
	High Yield Savings
	Money Market Savings (minimum opening deposit $1,000.00) Please choose if you would like to receive checks for this account type
		With Checks
		Without Checks
	Individual Retirement Account (minimum opening deposit $25.00)
		Traditional
		Roth
		Education
	Christmas Club
	Other Club

*	Today's Date

	Primary Signer Information
*	Last Name
*	First Name
	Middle Initial
*	Residential Address Not P.O. Box
*	City
*	State
*	Zip
	Mailing Address If different
	City
	State
	Zip
*	SS#	- -
*	Date of Birth (MM/DD/YYYY)	/ /
*	Are You a U.S. Citizen?	Yes No
*	Mother's Maiden Name
*	First School Attended
*	Home Phone Number
*	Work Phone #
*	E-mail Address
	Secondary Signer
*	Last Name
*	First Name
	Middle Initial
*	Residential Address Not P.O. Box
*	City
*	State
*	Zip
	Mailing Address If different
	City
	State
	Zip
*	SS#	- -
*	Date of Birth (MM/DD/YYYY)	//
*	Are You a U.S. Citizen?	Yes No
*	Mother's Maiden Name
*	First School Attended
*	Home Phone Number
*	Work Phone #
*	Email Address

	Other Services Requested
	Master Money Debit/ATM Card - Checking Accounts Only (primary signer)
	Master Money Debit/ATM Card - Checking Accounts Only (secondary signer)
	ATM Card (primary signer)
	ATM Card (secondary signer)
	Please check any additional services you are interested in. We will provide additional information to you via mail:
	Direct Deposit
	Payroll Deduction
	Tele-Touch � 24 hour account information by phone
	Overdraft Protection - from statement savings account

*	Certification
	Under penalties of perjury, I certify that the number shown on this form is my correct taxpayer identification number and (check one)
		I am not subject to backup withholding either because (a) I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends or (b) the Internal Revenue Service has notified me that I am no longer subject to backup withholding
		I have been notified that I am subject to backup withholding. (The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding
	IMPORTANT: PLEASE READ THE FOLLOWING BEFORE SIGNING OR SUBMITTING YOUR APPLICATION
	a)	I have read and understand the account disclosures for the products for which I am applying.
	b)	I plan to open the account(s) indicated in the summary at the top of this application.
	c)	If I/we are applying for a Rockland Federal Credit Union Master Money Card, I/We understand that it is not a credit card and that the dollar amount of the transactions and purchases will be deducted from my/our Rockland Federal Credit Union checking account only.
	d)	I have read and understand the contents of this application.
	e)	The information provided to Rockland Federal Credit Union is true to the best of my knowledge and I understand that Rockland Federal Credit Union will obtain clearance through either a national check service or credit bureau agency.
	f)	This application will be retained by Rockland Federal Credit Union whether or not is approved.
	g)	I agree that this account is governed by all applicable Federal Laws and Regulations and the laws of the State of Massachusetts.
	IMPORTANT: BE SURE TO SIGN BELOW BEFORE MAILING IT TO US. NEW MEMBERS: PLEASE SEND IN A COPY OF YOUR LICENSE(S) WITH YOUR SIGNED APPLICATION. Primary Signer ___________________________________________ Secondary Signer _________________________________________
	Important Terms and Conditions (Including Electronic Funds Transfer and Funds Availability) Term Certificate Truth in Savings Disclosure Privacy and Security Statement The information you send to RFCU on this form will be encrypted for your privacy and protection.