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SELF RELIANCE (NY) FEDERAL CREDIT UNION
· 108 2ND AVE NEW YORK, NY 10003-8302
· (212) 473-7310 OUTSIDE NYC 1-888-SELFREL
Online Enrollment Request
SELF RELIANCE (NY) FEDERAL CREDIT UNION INTERNET BANKING APPLICATION/AGREEMENT ACCOUNT HOLDER INFORMATION: __________________________________________ ___________________________ Name as it appears on the Account SS# or tax ID __________________________________________ ___________________________ Street Address City, State and Zip __________________________________________ ___________________________ E-mail address Telephone Number SERVICE REQUESTED New Application for SRNYFCU Internet Banking Amendment to existing Internet Banking Agreement ACCOUNTS DESIGNATED FOR INTERNET ACCESS Please write the account number of each account you wish to access through the Self Reliance (NY) Federal Credit Union (SRNYFCU) Internet Banking system. Account Number and suffix Type of account Ownership type If additional space is needed please attach listing to this form and initial this box: INTERNET BANKING SYSTEM USERS Please list all persons to whom you will give access to do Internet Banking on your behalf: User Name Social Security Number SERVICE AGREEMENT: By signing below: 1. I/We will be bound by the terms and conditions of SRNYFCU's Truth in Savings Agreement which SRNYFCU may amend from time to time. 2. I/We understand that a User ID and temporary password will be issued to me/us within 2 business days of receipt of this application. I/We must change the temporary password to a private password the first time I/we log on to the SRNYFCU Internet Banking system. I/We also understand that the passwords can be used to withdraw funds from the account(s) and that I/we must safeguard all passwords. I/We authorize SRNYFCU and its agents to follow any instructions transmitted by the use of these passwords, and agree to be bound thereby. 3. I/We authorize SRNYFCU to disclose information about any of my SRNYFCU accounts to third parties (including Payees) in order to complete transactions using Internet banking. I/We authorize my Payees to disclose to the financial institution and/or its agents information regarding my account(s) with such Payees in order to complete transactions using Internet Banking, including resolving questions regarding such transactions. 4. I/We certify that everything that has been stated in this application and on any attachments is correct. SRNYFCU is authorized to retain this application whether or not it is approved. Also, I/we understand that SRNYFCU may cancel/terminate my Home Banking privileges at any time. 5. I/We accept the terms and agreements outlined in the Electronic Fund Transfer Act Disclosure. ___________________________________ _______________ Account Holder or Authorized Signer Date ___________________________________ _______________ Account Holder or Authorized Signer Date MSR ACCEPTING APPLICATION ________________ _______________ Date MSR setting up Home Banking on System ________________ _______________ Reviewed by:_______________ Date GKB8/4/2007