NCUA 4012 Report of Official and Agreement to Serve

OMB No. 3133-0015

REPORT OF OFFICIAL AND AGREEMENT TO SERVE
TO: NATIONAL CREDIT UNION ADMINISTRATION

Federal Credit Union

Proposed
Title of Prospective Position:
Name: Mrs.
Maiden Name: (If Different From Above)
Address (Res.): Street:
City:
State:
Zip Code:
Telephone Number:
Place of Birth:
Date of Birth:
Employer:
Social Security Number (Optional):
Type of Business:
Number of years with present employer:
Your position title:

Education background (enter highest grade completed)
High School:
College:
Major Field of Study:

Other training or experience:



Are you willing to accept the position of trust for which you have been
selected and to remain in office until a qualified successor is found?

Yes

No

Have you been informed as to the general duties and responsibilities
of an official of the proposed Federal Credit Union and are you willing
to devote the time necessary to familiarize yourself with and to
perform your duties?

Yes

No

Yes

No

Estimated number of hours per month you will be able to volunteer:
IF THE ANSER IS YES TO THE FOLLOWING QUESTION, PLEASE
PROVIDE INFORMATION AS INSTRUCTED ON THE FOLLOWING PAGE:
Have you ever been convicted of any CRIMINAL OFFENSE
involving dishonesty or a breach of trust?

To facilitate the process of obtaining a credit and background check, please provide the following:
1. Any other names which you have used:
2. Previous address (if your address changed over the past 2 years):
3. Name of Spouse:



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VHFXULW\QXPEHURQWKLVIRUPFile Typeapplication/pdfFile Title2002-NCUA_40121-15wAuthorJoeOFile Modified2016-10-21File Created2016-10-21