Membership Application

Preliminary Membership and Account Information

After submitting this application, you will be required to send a copy of two forms of valid identification for each account owner (state-issued driver’s license, state-issued ID card, Social Security Card or U.S. passport). With this information, we will create the Account/Signature Card for all parties to sign and return with any applicable minimum deposit ($5 savings deposit).

I am requesting:*

An individual account

A joint account

I would like to open the following account(s):*

Savings

Checking*

Visa® ATM/Debit card

A savings account is required in order to open a checking account. New members who want a checking account must also select the “Savings” option. For IRAs and minor, business, trust and estate accounts, please contact the New Accounts Department at 281.479.6651, option 3.

I would like to add the following Payable On Death (POD) Beneficiary(ies):

For joint accounts, each owner has right of survivorship—meaning that when one owner dies, the other will automatically become the sole owner of the account. If you add a POD designation to a joint account, it will take effect only when the second owner dies. Adding a POD designation is optional but highly recommended for Individual Accounts.

Beneficiary #1 - Name

Beneficiary #1 - Date of Birth

Beneficiary #1 - Social Security Number

Beneficiary #1 - Address (optional)

Beneficiary #2 - Name

Beneficiary #2 - Date of Birth

Beneficiary #2 - Social Security Number

Beneficiary #2 - Address (optional)

I would like to set up Payroll Deduction (Lubrizol employees only)

This does not affect or change any currently Direct Deposit set up with another financial institution. If you would to like switch your direct deposit from another financial institution to your account with LZECU, please make that change with the Payroll Department.

Per paycheck, please deduct a total of:

Amount to Savings:

Amount to Checking:

Owner/Signer Information #1

Name:

Address

Mailing Address (if different)

Home Phone

Work Phone

Mobile Phone

Email Address*

Birth Date

SSN/TIN

Gov.-Issued Photo ID (Driver’s License #, Exp. Date, State)

Mother’s Maiden Name (security question)

Employer/LZ Emp. #

Member Qualification/LZ Dept. #

Owner/Signer Information #2

Name

Address

Mailing Address (if different)

Home Phone

Work Phone

Mobile Phone

Email Address

Birth Date

SSN/TIN

Gov.-Issued Photo ID (Driver’s License #, Exp. Date, State)

Mother’s Maiden Name (security question)

Employer/LZ Emp. #

Member Qualification/LZ Dept. #

TERMS & AGREEMENT

After clicking "submit", your information will be sent securely to a financial services representative.

By submitting this application below, I certify, under penalties of perjury, that (1) I am a U.S. person (Incuding a U.S. resident- alien).(2) the Social Security Number (SSN)/Taxpayer Identification Number (TIN) shown is my/the correct identification number and (3) I am authorizing that a routine credit report can be obtained which will provide information concerning my credit worthiness.

PATRIOT ACT NOTICE : 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 for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.

*

I AGREE

Signature*