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Membership Application

Membership Eligibility - you must live or work in Linn County or the surrounding counties to qualify for membership.

Before you begin: It will take you about 10 minutes to complete this application. Please provide all the requested information. When you have completed the form please press the submit button to send your application to the Credit Union. We will be contacting you with new account information and agreements within 2 - 3 business days.

Once you receive the paper work, you will need to: (1) Have all joint applicants sign the signature card in the presence of a Notary. (2) Mail back the top copy of the signature card along with a clear copy of your valid Drivers License or State ID card. (Your account is not open until a signed signature card from all owners is received by CCCU.)

Note: All transactions are secure.


Required fields are marked with an asterisk *
Individual Account Joint Account  Other (explain) 


Applicant 
First Name* 
 
Last Name* 
 
Middle Initial* 
 
Male Female 
Address* 
 
City* 
State/Province* 
ZIP/Postal Code* 
 
County 
Social Security Number* 
- -
Date of Birth* 
 
Home Phone* 
 
Cell Phone 
 
Home E-mail 
Employer* 
 
Work Phone 
 
Work E-mail 

Drivers License
Number*  
State   
Co-Applicant 
First Name 
 
Last Name 
 
Middle Initial 
 
Male Female 
Address 
 
City 
State/Province 
ZIP/Postal Code 
 
County 
Social Security Number 
- -
Date of Birth 
 
Home Phone 
 
Cell Phone 
 
Home E-mail 
Employer 
 
Work Phone 
 
Work E-mail 

Drivers License
Number  
State   

Best Time to Call   Daytime 
Home Phone Work Phone Cell Phone Home Email  Work Email 
Select type of Account
Share Savings Share Savings Plus
Fortune 50 Club Ages 50 + Kirby Kangaroo (Trust) Ages 0-12
STAR Account Ages 13-23 Christmas Club
Vacation/Thrift Basic Share Draft
Share Draft Plus  
Comments
that Collins Community Credit Union obtain credit reports on me/us from time to time. I/We understand that Collins Community Credit Union will use the credit reports in evaluating my/our credit worthiness for various credit products offered by the institution.   

Certification and Agreement
(1) The number(s) shown in this application is/are the correct taxpayer identification number(s) and I/we am/are not subject to backup withholding either because I/we have not been notified that I/we am/are subject to backup withholding as a result of failure to report all interest or dividends, or the IRS has notified me/us that I/we am/are no longer subject to backup withholding.   

(2)  by the IRS that I/we am/are subject to backup withholding due to notified payee underreporting and I/we have been notified that the backup withholding is terminated.   

(3) I/we agree to be bound by the provisions of the applicable disclosure(s) for products I/we have selected. Collins Community Credit Union will furnish such applicable disclosure(s) to me/us within the timeframe(s) prescribed by regulation and I/we will inform this Collins Community Credit Union if I/we do not receive full disclosure(s).   
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