| Application and Member Information | |
|---|---|
| Account Number: | Member Name: |
| Street: | City/State/Zip: |
| Home Phone: | Work Phone: |
| Joint Owner Information (If Applicable) | |
| Joint Owner: | |
| Street: | City/State/Zip: |
| Home Phone: | Work Phone: |
| I/We request the following services (please mark): | |
| Debit Card | |
| Online/PC EFTs | |
| Bill Payment | |
| By checking the boxes above and signing below, you certify that the information on this application is complete, true, and submitted for the purpose of obtaining the electronic service(s) and account(s) requested. If approved for the requested electronic funds transfer services, you acknowledge receipt of and agree to the terms of the Electronic Fund Transfers Agreement. | |
|
Signature of Member:_____________________________________________ Date:_______/_________/__________ Cardholder Signature of Joint Owner:_______________________________________ Date:_______/_________/__________ |
|
Approved By:____________________________ Member Verification: ________________
Access Card: ________________________PIN Requested:______________________