eBRANCH Application

SMARTLine/e-BRANCH Application Form

Please complete this form and drop off at the nearest branch office or mail to:

PFCU
P.O. Box 778
Chambersburg, PA 17201-0778
ATTN.: Member Services

Your Information

_______________________________________________
First Name
_______________________________________________
Last Name
_______________________________________________
Credit Union Account Number
_______________________________________________
E-mail address
_______________________________________________
Street Address
_______________________________________________
City State Zip
_______________________________________________
Your Social Security #
_______________________________________________
Mother's Maiden Name
_______________________________________________
Work Phone Number
_______________________________________________
Home Phone Number

Joint Owner Information
_______________________________________________
First Name
_______________________________________________
Last Name

Account Access
I understand that I may only send funds from the above listed account. A separate SMARTLine/e-BRANCH agreement is required to send funds to the account.

Please check the appropriate box:

Yes ? I authorize PFCU to activate the SMARTLine/e-BRANCH option to transfer funds from my account number listed above, to the following designated account number(s): ________________ ________________ ________________ Example: If you want to be able to transfer money from your account into a child's account list the child's account number above.

NO ? I do not wish to activate transfers to other account numbers at this time.

Authorization
By evidence of the signature hereon, I agree that the retention or use of the SMARTLine/e-BRANCH System provided by the Patriot Federal Credit Union shall be governed by the terms and conditions of PFCU and any other terms and conditions or amendments provided from time to time. I have read the disclosure and agree to all the terms and conditions contained herein.

Upon receipt of your SMARTLine/e-BRANCH System application, a preassigned Personal Identification Number (PIN) will be mailed to your current address. If you wish, you may change your PIN by accessing audio response service code 41#.

Copy Received: I hereby make application and acknowledge receipt of a copy of this SMARTLine/e-BRANCH User's Agreement and Disclosure.

All fees and policies are subject to change without notice.

X_______________________________________________
Primary Member Signature
______________
Date

X_______________________________________________
Joint Member Signature
(required when joint accounts are specified)
______________
Date

Sign and return this application to your branch, or mail to the credit union.

Once your application is processed, you will receive confirmation and further information via e-mail or U.S. mail.