DocuSign Envelope ID: 38860BA7-37E9-4254-A43B-D41D5368637C
Membership Application P.O. Box 418 Laurel MD 20725
aplfcu.org 443-778-5250 (Baltimore)
240-228-5250 (Washington DC)
1-800-367-5796 (Toll Free Out of Area)
Today’s Date: 4/20/2023 Member #: 571280 Account #: 1
Account Type: SAVINGS Eligibility for Membership: HOWARD CO.-LIVE
If eligible due to Family, Relationship: Name:
Ownership: (If more than one Owner, membership will be a Joint Membership)
Primary Owner’s Name: KELLI AMBER SOUSTEK SSN/TIN: 214-29-9300
Date of Birth: 5/22/1990 Citizenship Status: USCITIZEN
Mother’s Maiden Name: MARTIN Phone Password: 102010
ID Type: DRIVERS_LICENSE ID #: S232465066386 ID State: MD
ID Date Issued: 5/22/2017 ID Expiration Date: 3/28/2024
Physical Street Address: 9564 PATCHIN COURT
City: COLUMBIA State: MD ZIP: 21045
Phone – Home: (443) 989-4331 Work: Cell: (443) 989-4331
Joint Owner’s Name 1: SSN/TIN:
Date of Birth: Citizenship Status:
Mother’s Maiden Name: Phone Password:
ID Type: ID #: ID State:
ID Date Issued: ID Expiration Date:
Physical Street Address:
City: State: ZIP:
Phone – Home: Work: Cell:
Joint Owner’s Name 2: SSN/TIN:
Date of Birth: Citizenship Status:
Mother’s Maiden Name: Phone Password:
ID Type: ID #: ID State:
ID Date Issued: ID Expiration Date:
Physical Street Address:
City: State: ZIP:
Phone – Home: Work: Cell:
DocuSign Envelope ID: 38860BA7-37E9-4254-A43B-D41D5368637C
JOINT MEMBERSHIP AGREEMENT
The Credit Union is hereby authorized to recognize any of the signatures subscribed on the Membership Application in the
payment of funds or the transaction of any business for my/our membership. The joint owners of this membership agree with
each other and with the Credit Union that all sums now paid in on any account under this membership, or heretofore are
thereafter paid in by any or all said joint owners to their credit as such joint owners with all accumulations thereon, are and shall
be owned by them jointly, with right of survivorship and subject to the withdrawal and receipt of any of them and payment to
any of them or the survivor or survivors shall be valid and discharge the Credit Union from any liability for such payment. The
right or authority of the Credit Union under this agreement shall not be changed or terminated by said owners, or any of them
except by written notice to the Credit Union which shall not affect transaction therefore made. I/we understand that any accounts
opened under this membership number now or in the future will be owned by all joint owners on file unless a signed Services
Request Form – Remove Joint Owner is on file waiving joint owner rights.
OVERDRAWN ACCOUNTS
The owner and joint owner (if any) agree to be jointly and severally liable for negative balances on any accounts in which either
or both owners have an ownership interest, including any overdrafts, regardless of the cause, and agree to immediately deposit
sufficient funds to cover the negative balance. The owner and joint owner (if any) agree that APL Federal has the right to
transfer funds from any accounts, in which either have an ownership interest, to correct a negative or overdrawn amount on
any account on which either of their names appear. The owner and joint owner agree to reimburse APL Federal for all costs of
collection, including reasonable attorney’s fees.
TAXPAYER IDENTIFICATION NUMBER CERTIFICATION
The Internal Revenue Service does not require your consent to any provision of this document other than the
certifications required to avoid backup withholding.
Have you been 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? _____
NO
Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer identification number (or I
am waiting for a number to be issued), and (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. citizen or other U.S. person. For federal tax purposes, you are considered a U.S. person if
you are: an individual who is a U.S. citizen or U.S. Permanent Resident Alien; a partnership, corporation, company, or
association created or organized in the United States or under the laws of the United States; an estate (other than a foreign
estate); or a domestic trust (as defined in Regulations section 301.7701.7).
AUTHORIZATION
By signing below, I/we certify all the above information to be true and correct, acknowledge receipt of the Disclosure Statement
Booklet and agree to the terms and conditions of it, 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 agreements, Fee Schedule and disclosures applicable to
the accounts and services requested herein and agree to their terms and conditions. I authorize APL Federal Credit Union to
verify the information to be accurate through the use of third party agencies to include credit reporting agencies. I understand
that APL Federal Credit Union may request reports from these agencies to evaluate my membership standing at any time.
5/17/2023 | 3:11 AM EDT
Primary Owner’s Signature Date Joint Owner 1 Signature Date
Joint Owner 2 Signature Date
