Online Bill Pay Application

Account Number (77)

General Applicant Information

First Name Last Name Middle Initial Street Address City State Zip Home Phone Number Work Phone Number Cell Phone Number Email Address

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Signature(s) Required: I/We acknowledge that I/we have received a copy of your First Class Online Bill Pay Agreement, and fee schedule. I/We have read, understand and agree to be legally bound by the terms and conditions of such Agreement. In addition, I/we hereby authorize First Class FCU to obtain a credit report(s) to check my/our history for any or all services. I/We also acknowledge receipt of the disclosure statement informing me/us of our rights under the Electronic Funds Transfer Act. I/We acknowledge that I/we will no longer receive "physical statement(s)" but rather electronic statements that can be printed by me/us. In addition, I/we agree to receive all future statements, disclosures and notices where available to the e-mail account listed on this application.

* If your account is a joint account, all owners must sign.

Applicant's Signature Applicant's Signature Joint Account Applicant's Signature Joint Account