Date: 04/13/2005

The company/organization listed below does hereby apply to become a Select Employee Group (SEG) of Saginaw County Employees Credit Union.

This request will allow all employees of the company/organization and their families to become eligible to receive the benefits of membership through Saginaw County Employees Credit Union.

The company/organization understands that there is no cost involved in this request and that the request is for the purpose of extending membership as a benefit to the company's/organization's employees and/or members.

Company/Organization Name*

Street Address* 
City*    State*  AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NE NC ND NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY   ZIP* 
Company Telephone* E-Mail Address
Number of Employees      Current Credit Union (if any)

Signature of President/Acting Officer of the Company/Organization*

X______________________________________________________________
Name      Title