Personal Information Last Name* First Name* M.I. SSN/TIN* Address* City* State* Zip Code* County* Home Phone* Birthdate* (mm/dd/yyyy) Email Address* Driver's License Number* State* Expiration Date* (mm/dd/yyyy) Mother's Maiden Name* Eligibility Eligibility for Membership* Event Code (if applicable) Employer* Job Title* Work Phone* Employer Address* City* State* Zip Code* Important Information Finalizing Your Application A Member Service Representative will contact you to further determine how you would like to finalize opening your account at Heritage South Credit Union. 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. You hereby authorize us, our employees or agents to obtain credit reports in relation to this application or during anytime you are obligated to us for the repayment of any debt, and investigate and verify any information provided to us by you. Prior to submitting the application, please enter the security code in the box below. By clicking on the “SUBMIT” button, you affirmatively consent to conduct business electronically with Heritage South Credit Union in connection with your online membership application and consent to the receipt of the electronic disclosures shown above.