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Membership Application

Do you meet the membership requirement?

Persons who live, work, worship, or attend school in, and businesses and other legal entities located in these counties in South Dakota:

Clark
Codington
Deuel
Grant
Hamlin

PRIMARY OWNER’S INFORMATION

Name

First Name

Last Name

Social Security Number

Physical Address: Street (No PO Box)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address (if different than physical address)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Date of Birth

Place of Employment/Position

Mother's Maiden Name

Driver's License Number

JOINT MEMBER INFORMATION

Name

First Name

Last Name

Social Security Number

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Date of Birth

Place of Employment/Position

Driver's License Number

Authorization Notice: By submitting this application to the credit union, you certify that everything you have stated is correct to the best of your knowledge. You understand that the credit union will rely on the representations you make in this application when deciding whether to grant membership. You agree to immediately notify us of changes to any of the information you have provided in this application. You understand that it is a federal crime to willfully and deliberately provide incomplete or incorrect information on applications made to Credit Unions insured by NCUA.

Membership Application

Do you meet the membership requirement?

Main Branch

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