Business Member Information Please provide the following information about your business: Question Title Full Legal Name of Business Question Title Are you a current WCCU BUSINESS MEMBER? Yes No, I would like more information about becoming a Business Member. Question Title Please enter Member # Member Number: I am currently not a member, please check with an X Question Title List Legal Name of Business in Directory Yes No Question Title Business Information Physical Business Address City/Town State/Province ZIP/Postal Code County/Counties the Business Serves Business Email Address Business Phone Number Question Title Business Website Link Question Title Business Contact Name Name Business Contact Address (for internal use only) City/Town State/Province ZIP/Postal Code Business Contact Email Address Business Contact Phone Number Question Title List Business Contact Name in Directory Yes No Question Title Best Contact Method Phone Email Question Title Primary Business Activity Question Title Business Type (Please select one) Accommodation & Food Services Agriculture, Animal Care, Forestry, Fishing and Hunting Administration, Business Support and Waste Management Services Arts, Entertainment and Recreation Automotive and Transportation Construction, Construction Trades Healthcare and Social Assistance Educational Services, Information Technology, Telecommunications Professional, Scientific, Technical (Including Finance/Insurance) Manufacturing, Crafts, Wood/Furniture Manufacturing Real Estate, Rental and Leasing Personal Services, Hair/Nail Salons Utilities Question Title Business Bio Question Title Authorization & Acknowledgement:By executing this form below, the undersigned, on behalf of the entity identified herein, warrants, and represents that he/she is duly authorized to sign name and permit the disclosure of the information contained herein, including but not limited to the fact that said entity is a member of Westby Co-op Credit Union. Further, by executing this form, the undersigned, on behalf of said entity authorizes Westby Co-op Credit Union to publish the above information on its Business Member Directory, located on the Westby Co-op Credit Union website. The undersigned acknowledges that the business account must be a member in good standing to be published in the Business Member Directory, and if at any time the business is not in good standing, Westby Co-op Credit Union reserves the right to remove any information relating to the entity from the website and directory. I accept Question Title Disclaimer:Westby Co-op Credit Union shall only disclose the facts set forth herein, and likewise, that the identified business entity is a member of Westby Co-op Credit Union. No other protected and confidential financial information will be disclosed on Westby Co-op Credit Union’s website, the Business Member Directory, or directly to any third-party. Westby Co-op Credit Union complies with all state and federal laws and regulations related to the protection of protected and confidential financial information. I have read and understand the Business Member Directory Disclaimer Question Title Authorized Signer Signature (By providing your initials below, you are signing and accepting the terms and conditions of the WCCU Business Member Directory Authorization Form.) Date Authorized Signer Initials Submit
