Member Survey

Survey- Proposed African Diaspora Federal Credit Union
Return Completed Survey to 1425 Ferguson Avenue, Saint Louis, MO. 63133 USA with your

First Name* Last Name*
Address* City* State* Zip Code*

Tel#* Email

Are you interested in joining the Proposed African Diaspora Federal Credit Union within two years of it being open? YesNo
If NO, please answer question 2. Briefly explain why not in question 12 and return the survey to the above address.
Are you currently a member at a credit union or customer at a bank? *

Member at a Credit UnionCustomer at a BankOther

If the other box is checked, Please explain

Please indicate which of the following products and services are Desired or Necessary for you to join the credit union (use a D for Desired and N for Necessary):

Savings/Shares	Loans	Other Services	Other Services
Savings:	Signature:	Over Draft:	Money Order:
Checking:	New Vehicle:	Debit Card:	Cashier Checks:
Shares Certificate:	Used Vehicle:	ATM Card:	Direct Deposit:
IRA:	First Mortgage:	Online Banking:	Wire Transfer:
Business Checking:	Home Equity:	Online Bill Pay:	Notary:
Other:	Credit Card:	Financial Counseling:	Other:
	Other:	Telephone Banking:

If any of the "Other" boxes are checked, please explain

Would you be willing to pledge an initial donation to support the startup expenses in the credit union? *YesNo If yes, how much would you be willing to donate?

$250

$500

$750

$1000

Other
Would you be interested in making regular deposit (such as payroll deposit) in the credit union? *YesNo If yes, how much would you deposit monthly? $

If you checked any of the "Savings/Shares" boxes above, please complete following question as applicable.

Which of the following average balances for the share account would you be able to keep in the credit union?

Share Type	$0- $300	$301- $500	$501- $1000	$1001- $2000	$2001- $2500	$2501- $3000	Over $3000
Savings
Checking
Share Certificate
IRA
Business Checking
Other

Which of the following average balance for each share certificate term (i.e. Maturity date) would you be able to keep in the credit union?

Share Certificate Type	$0- $300	$301- $500	$501- $1000	$1,001- $1500	$1501- $2000	$2001- $2500	$2501- $3000	Over $3000
6 Months
12 Months
24 Months
Over 24 Months

If you were to acquire any of the "Loans" boxes in #3, Please complete the following question as applicable.

If you were to acquire a loan in the next 12 months, which of the following ranges represent the amount you might borrow for each type of the loan you are interested in?

Loan Type	$0- $500	$501-$1000	$1001-$5000	$5001-$10000	Over $10000
Signature
New Vehicle
Used Vehicle
1st Mortgage
Home Equity
Credit Card
Other

When transacting credit union business which of the following ways would you use? Please use 1 for the most preferred way and 7 for the least preferred way

	Visit the Credit Union Office
	ATM
	Online Banking
	USPS Mail Services
	Telephone Banking
	Automated Telephone Banking
	Other, please explain

Would you be interested in being a volunteer official at the credit union? *YesNo
Please provide your name and address if you answered yes to #10 or would like more information about Proposed African Diaspora Federal Credit Union, including when you can join.

First Name

Last Name

Address

City

State

Zip Code

Telephone Number

Email Address
Please provide us with any other thoughts or comment you would like to share with us.

Refer Friends (you can add multiple email addresses separated by a comma(e.g one@email.com,two@email.com))
How did you hear about us?

Please provide friend's email/platform name if you choose Referred by a friend/Other.

Print Name*

Signature [signature* signature-309 class:signtaur-box cols:500 color:#000]

Donate your pledgePrint