CHECKING REQUEST FORM

Transcription

1 CHECKING REQUEST FORM Please provide all requested information. When you have completed this form, fax it to (919) or mail it to: ElecTel Cooperative Federal Credit Union, PO Box 27306, Raleigh, NC Upon receipt, we will complete your new account paperwork ahead of time. PRIMARY MEMBER INFORMATION (PLEASE PRINT) Member Number (if you are already a member and have one) First Name Middle Initial Last Name Social Security Number Date of Birth (mm/dd/yyyy) Home Phone ( ) Work Phone ( ) Employer Residential Address City State Zip Driver s License Number State Date of Issuance Expiration Date How are you eligible for membership? We call Chex Systems. In what state have you lived in the past 5 years? JOINT OWNER INFORMATION (PLEASE PRINT) NOTE: Must be the same joint owner as on primary savings account. Member Number (if you are already a member and have one) First Name Middle Initial Last Name Social Security Number Date of Birth (mm/dd/yyyy) Home Phone ( ) Work Phone ( ) Employer Residential Address City State Zip Driver s License Number Date of Issuance State Expiration Date

2 DIRECT DEPOSIT AUTHORIZATION NAME OF COMPANY MAKING DEPOSIT Please Deposit: my entire check or part of my check to the following account: $ ElecTel Cooperative Federal Credit Union FINANCIAL INSTITUTION CHECKING SAVINGS

3 CHANGE DIRECT DEPOSIT NAME OF COMPANY MAKING DEPOSIT You are currently depositing: my entire check or part of my check to the following account: $ CURRENT FINANCIAL INSTITUTION Please stop making deposits to the above account and instead make the same deposits to: ElecTel Cooperative Federal Credit Union account CHECKING SAVINGS

4 DIRECT DEPOSIT NAME SOCIAL SECURITY NUMBER EMPLOYER SECTION 2 I HEREBY AUTHORIZE MY EMPLOYER TO INITIATE CREDIT ENTRIES TO MY ACCOUNT AS INDICATED ABOVE. IF FUNDS TO WHICH I AM NOT ENTITLED ARE DEPOSITED IN MY ACCOUNT, I AUTHORIZE MY EMPLOYER TO DIRECT ELECTEL TO RETURN SAID FUNDS. THIS AUTHORITY IS TO REMAIN IN EFFECT UNTIL THE COMPANY HAS RECEIVED TIMELY WRITTEN NOTICE FROM ME OF TERMNATION OR UNTIL THE COMPANY OR FORUM HAS SENT ME TEN DAYS WRITTEN NOTICE OF TERMINATION OF THIS ARRANGEMENT. THE COMPANY MAY ALSO SUSPEND THIS ARRANGEMENT TO FULFILL LAWFUL WAGE ATTACHMENT ORDERS. I UNDERSTAND I AM RESPONSIBLE FOR THE VALIDITY OF THE INFORMATION ON THIS FORM. EMPLOYEE WORK PHONE ADDRESS PAY DISTRIBUTION SAVINGS $ SHARE DRAFT/CHECKING $ CHRISTMAS CLUB $ SPECIAL SAVINGS $ LOAN PAYMENT $ OTHER: $ RELATED ACCOUNT # $

5 CHANGE AUTOMATIC PAYMENT (MAKE COPIES OF THIS FORM AS NEEDED) NAME OF COMPANY MAKING AUTOMATIC WITHDRAWALS You are currently withdrawing $ AMOUNT from my checking account on WHEN for WHAT PAYMENT IS FOR paid to ACCT NUMBER RECEIVING PYMT It is being withdrawn from the following account: PREVIOUS FINANCIAL INSTITUTION Please stop making withdrawals to the above account and instead make them from: ElecTel Cooperative Federal Credit Union account CHECKING SAVINGS

6 AUTOMATIC PAYMENT CANCELLATION (MAKE COPIES OF THIS FORM AS NEEDED) NAME OF COMPANY MAKING AUTOMATIC WITHDRAWALS You are currently withdrawing $ AMOUNT from my checking account on WHEN for WHAT PAYMENT IS FOR paid to ACCT NUMBER RECEIVING PYMT It is being withdrawn from the following account: PREVIOUS FINANCIAL INSTITUTION Please stop making withdrawals from the above account:

7 AUTOMATIC PAYMENT AUTHORIZATION (MAKE COPIES OF THIS FORM AS NEEDED) NAME OF COMPANY MAKING AUTOMATIC WITHDRAWALS Please withdrawal $ AMOUNT from my checking account on WHEN for WHAT PAYMENT IS FOR paid to ACCT NUMBER RECEIVING PYMT from the following account: ElecTel Cooperative Federal Credit Union FINANCIAL INSTITUTION CHECKING SAVINGS

8 CLOSE EXISTING ACCOUNT EXISTING FINANCIAL INSTITUTION S NAME Please close my account, and send a check, including all dividends accrued, for the remaining balance to me at the address listed below. JOINT ACCOUNT OWNER NAME (PRINT) JOINT ACCOUNT OWNER