1481 Harlem Road Cheektowaga, NY 14206 • Phone: (716) 897-2383 • Email: memberservices@bufconfcu.com

Member Information
Primary Information

Buffalo Conrail FCU Member Application

Will this be a Single or Joint Application? *

Which account type would you like to open? *

Account Services

No dashes, spaces, or parentheses

No dashes, spaces, or parentheses

No dashes, spaces, or parentheses

Employment information

Beneficiary

Beneficiary cannot be a signer on the account.

Disclosure and Agreement to Terms

Under penalty of perjury, I certify that:
1. The number shown on this form in my correct taxpayer identification number.
2. I am not subject to backup withholding because a. I am exempt from backup withholding, or b. I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or c. the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. person (including U.S. resident alien )

Certification Instructions. Cross out item 2 above if you have notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.

By signing below, I/we agree to the terms and conditions of the Membership and Account Agreement, Truth-In-Savings Disclosure, Funds Availability Policy Disclosure, 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 Disclosure applicable to the accounts and services requested herein. If an access card or EFT service is requested and provided, I/we agree to the terms of and acknowledge receipt of the Electronic Funds Transfer Agreement. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

Do you agree with the above terms and conditions? *

Joint Information

Joint Applicant - Personal information

No dashes, spaces, or parentheses

No dashes, spaces, or parentheses

No dashes, spaces, or parentheses

Employment information

Co-Applicant

Do you agree with the above terms and conditions? *