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BLACK SHOPPERS UNION

CIPCARDTM MEMBERSHIP APPLICATION FORM
TheCIPCARDTM Allows members to benefit from a variety of Financial Services such as POS transactions,wire transers,prepaid calling card feature,payroll services and more!
TheCIPCARDTM can be used at over a million retailers and internationally at any STAR® or PLUS® ATM.You control the amount of money you want to transfer to your companion card, anytime, daily, weekly, monthly, it's up to you!
Note: All information must be completed
Primary Member Information

Name:

Date:

 Choose Date

Address:

City:

Zip:

State:
Area Code and Phone Number:

Email:

Date of Birth:

 Choose Date

*Social Security Number:

Are you a U.S. Citizen

 ID/Drivers License#:
Other Information: (Only if you do not have a Social Security Number)
  • Taxpayer I.D. Number:
  • Alien I.D. Card Number:
  • Passport Number:

Country of Issuance:
Check One:

* Please note that SSN is for ID purposes only. There is NO CREDIT CHECK
Non Profit Organization Information

Organization Name:

Black Shoppers Union
Contact Name:

Kenneth Thomas
Cardholder Agreement
e-Sign Act
The E-sign disclosure and Consent(Disclosure) applies to all communications the Cipcard offered that are not otherwise governed by the terms and conditions of an electronic disclosure and consent.
 
 I understand my identity will be verified when I click "Submit"
For Membership Purpose
Username* :
Password* : (At least 6 characters)
Retype Password* :

 
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