Online Membership Application

Select membership type:*

Inclusiv

Full Name of CU*

Charter #

Year Chartered

Website

Mailing Address

*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Street Address

(if different than mailing address)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of CEO/Manager

First Last

Phone

Extension

Email

Primary contact for Inclusiv communications?

Yes
No

Name of Board Chair

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Primary contact for Inclusiv communications?

Yes
No

Primary Contact

Please add the contact information for the primary contact person at your credit union for Inclusiv communications, if it is not the CEO or Board Chair listed above.

Name

First Last

(if different from above)

Title

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

How do you prefer to receive communications?

Email
Regular mail

Please indicate your field of membership type:

Associational
Multiple fields
Employment based
Open
Community

How did you hear about us?

Are you low-income designated?

Yes
No

Are you CDFI certified?

Yes
No

Payment

For your security, we will contact you regarding payment information after we receive this form.

Membership Application

Mailing Address

Street Address

Primary Contact

Payment

Questions or Comments?

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