Authorization Code:
 New
Change
Cancel
I authorize you and Energy CU to initiate electronic
credit entries,
and if necessary, debit entries and adjustments for any credit entries in error to
my:
|
Checking Account # |  | $  | |
Savings Account # | | $ |
each pay period. This authority will remain in effect until I have cancelled it in
writing. |
| Financial Institution Information |
Account Holder Information |
| Financial Institution: Energy CU |
Name
(Please print): |
| Address:
156 Spring Street |
SS#: |
| City,
State, Zip: West Roxbury, MA 02132 |
Signature: |
| Employer Name: |
Date: |
| Address: |
| City,
State, Zip: |
