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Bellco Federal Credit Union

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					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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