Please complete all information requested below.

The information listed below are the account(s) I would like to setup for Online Banking. I understand that I must be listed on each account I am requesting access to.

Please Print

Name(s): ________________________________________________________________

Address: ________________________________________________________________

Phone: _________________________________________________________________

Account Number(s): _________________________

_________________________

_________________________

_________________________

_________________________

By signing below, I/we acknowledge receipt of a copy of the e*Teller Online Banking Disclosure and Agreement, a current copy which is available to you anytime at www.unisavfcu.org/eTeller Disc.html and/or in hard copy directly from us.

Signature: ______________________________________ Date: ___________________

Signature: ______________________________________ Date: ___________________

Fax this e*Teller Online Banking application to (925) 778-8174 or email to info@unisavfcu.org or mail to: PO Box 1409, Antioch, CA 94509