Member Number: ______________________
E-Mail Address: ____________________________________
Primary Owner: First
Name: ___________________MI: _____
Last Name: ___________________________
Primary Owner: Social Security #:
_______________________
Joint Owner 1: First
Name: ____________________MI:_____
Last Name: ____________________________
Joint Owner 2: First
Name: ____________________MI: _____
Last Name: ____________________________
Mailing Address: ____________________________________
City: ______________________State: _______Zip: ________
Home Phone Number: ________________________________
Account Number: Checking: ___________________
Account Number: Savings: ____________________
Account Number: ________: __________________
By signing below, I agree to the EBPS
Consumer Agreement and initial disclosures.
I also agree to a monthly fee of $8.00 for this service which will be
debited from the account listed automatically on the 5th day of the month.
Signature:
__________________________________________________
Date: _________________________
Once complete please return application to Triniservice Federal Credit Union to begin using the Bill Pay Service.