CHECKING REQUEST FORM

(1)

CHECKING REQUEST FORM

Please provide all requested information. When you have completed this form, fax it to (919) 876-8018 or mail it to: ElecTel Cooperative Federal Credit Union, PO Box 27306, Raleigh, NC 27611. 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 ( )

Email

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 ( )

Email

Employer

Residential Address

City State Zip

Driver’s License Number State

(2)

DIRECT DEPOSIT AUTHORIZATION

DATE

NAME OF COMPANY MAKING DEPOSIT

MAILING ADDRESS CITY, STATE, ZIP

To Whom It May Concern:

Please Deposit:

my entire check or part of my check to the following account: $

ElecTel Cooperative Federal Credit Union FINANCIAL INSTITUTION

253176930

FINANCIAL INSTITUTION ROUTING NUMBER

ACCOUNT NUMBER

CHECKING SAVINGS

If you have any questions about this request, please contact me at one of the following numbers:

Daytime: ( ) Evening ( )

NAME (PLEASE PRINT) SIGNATURE

(3)

CHANGE DIRECT DEPOSIT

DATE

NAME OF COMPANY MAKING DEPOSIT

You are currently depositing:

my entire check or part of my check to the following account: $

CURRENT FINANCIAL INSTITUTION

ACCOUNT NUMBER

Please stop making deposits to the above account and instead make the same

deposits to:

ElecTel Cooperative Federal Credit Union account.

253176930

ACCOUNT NUMBER

CHECKING SAVINGS

NAME (PLEASE PRINT) SIGNATURE

(4)

DIRECT DEPOSIT

NAME SOCIAL SECURITY NUMBER

DATE

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 SIGNATURE DATE WORK PHONE

ADDRESS CITY, STATE, ZIP

(5)

CHANGE AUTOMATIC PAYMENT

(MAKE COPIES OF THIS FORM AS NEEDED)

DATE

NAME OF COMPANY MAKING AUTOMATIC WITHDRAWALS

You are currently withdrawing $ from my checking account on

AMOUNT WHEN

for paid to

WHAT PAYMENT IS FOR ACCT NUMBER RECEIVING PYMT

It is being withdrawn from the following account:

PREVIOUS FINANCIAL INSTITUTION

ACCOUNT NUMBER

Please stop making withdrawals to the above account and instead make them from:

ElecTel Cooperative Federal Credit Union account.

253176930

ACCOUNT NUMBER

CHECKING SAVINGS

(6)

AUTOMATIC PAYMENT

CANCELLATION

DATE

You are currently withdrawing $ from my checking account on

AMOUNT WHEN

for paid to

It is being withdrawn from the following account:

PREVIOUS FINANCIAL INSTITUTION

ACCOUNT NUMBER

Please stop making withdrawals from the above account:

(7)

AUTOMATIC PAYMENT

AUTHORIZATION

DATE

Please withdrawal $ from my checking account on

AMOUNT WHEN

for paid to

from the following account:

ElecTel

Cooperative

Federal

Credit

Union

FINANCIAL INSTITUTION

253176930

ACCOUNT NUMBER

CHECKING SAVINGS

(8)

CLOSE EXISTING ACCOUNT

DATE

EXISTING FINANCIAL INSTITUTION’S NAME

Please close my account , and send a check, including all dividends

ACCOUNT NUMBER

accrued, for the remaining balance to me at the address listed below.

NAME (PLEASE PRINT) JOINT ACCOUNT OWNER NAME (PRINT)

SIGNATURE JOINT ACCOUNT OWNER SIGNATURE