Employer Partner Interest Form

Company/Organization Information

Legal Business/Organization Name *

DBA, if applicable

Physical Address *

Mailing Address, if different

City, State, Zip *

Main Phone Number *

Website Address

Choose the description that best describes your group: *

Company with employees (with or without volunteers)

All volunteer organization (e.g. volunteer fire company)

Club or member-based organization (Elks, Lions, etc.)

Number of Employees, Volunteers, or Members

Are you partnered with any other credit union(s)? *

Yes

If yes, list the other credit union(s)

Contact Information

Main Contact Name *

Main Contact Title *

Main Contact Phone Number *

Main Contact E-Mail *

Secondary Contact Name

Secondary Contact Title

Secondary Contact Phone Number

Secondary Contact E-Mail

Final Questions

How did you hear about us?

Questions or Comments

By clicking “Submit,” I certify that I am authorized to act on behalf of the organization listed above and I authorize the credit union to review this information for the purpose of determining eligibility. I also acknowledge that the information provided is accurate to the best of my knowledge.

Thank You — your information has been received.

You will be contacted by Ashley Goss within two business days.