E-Package Enrollment Form Please print out this form and return it to: Bellco Federal Credit Union 609 Spring Street Wyomissing, PA 19610 Please check which service(s) you are applying for: (You must be enrolled with Bellco @nywhere to receive e-statements) _____ Bellco @anywhere Online Banking _____ E-Statements _____ Bill Payer Please complete the following in its entirety: Name: ___________________________ Email Address: ___________________________________ Social Security Number: __________________________ Date of Birth: _________________________ Address: __________________________________________________ Daytime Telephone: __________________________ Evening Telephone: ________________________ Choose a PIN:____________________________________________ (Your PIN must be 7-15 characters in length and be a combination of letters and numbers, no spaces) Mother's Maiden Name: __________________________________________ Credit Union Account Number: _____________________________________ Primary Name on the Account: ______________________________________ Joint Owner's Name: ______________________________________________ If you have a joint owner on your primary account and want them to have access to Bellco @anywhere, please complete the following: Joint Owner's Social Security Number: _______________________ Joint Owner's Date of Birth: _______________________________ ___________________________________________________ YOUR SIGNATURE DATE ___________________________________________________ JOINT OWNER'S SIGNATURE DATE Disclosures: *E-Statement Opt Out Agreement: I would like to opt out of receiving my monthly paper statement from Bellco Federal Credit Union. I understand that by doing this I will be notified by email that my statement is available for review and it is my responsibility to retrieve it at my convenience. I also understand that I am responsible for supplying Bellco Federal Credit Union with the correct email address. If my email address should change, I will, in writing, inform Bellco Federal Credit Union of this change. I can do this By mail, fax of email. If I do not inform Bellco Federal Credit Union of a change in my email address, and Bellco Federal Credit Union, after two attempts, has to mail my statement to me, I agree to be converted back to a printed statement and charged a $5.00 fee for this conversion. If at anytime, I would like to stop receiving e-statements, I can do so by submitting a written request by mail, fax, or email to Bellco Federal Credit Union to receive a paper statement. There will be no charge for this change. I understand that by opting out of a printed statement I am entitled to Free Bill Payer, this service goes hand in hand with the above clause. If I am ever converted back to printed statements, either by Bellco Federal Credit Union, or myself, I will no longer qualify for Free Bill Payer. *Bill Payer Authorization: By signing above and checking Bill Payer, I am applying for Bellco Federal Credit Union’s Bill Payer service, acknowledge receipt of terms and conditions of this agreement and disclosure statement to which I agree to be bound; and that all information I have provided is accurate. By signing this enrollment form and checking Bill Payer, I am voluntarily contracting with Bellco Federal Credit Union to act as my agent, to include electronic remittance and origination provisions to any merchant I add to my Bill Payer Account.
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