PFCU Bill-Payment Authorization Application
(Please review the disclosure before filling out)

Using Internet Explorer, complete the application below. Then print and fax, mail, or bring to your nearest PFCU Office.

Choose From Two Convenient Plans (check one box only)
	Credit Union - originated plan for Fixed Payments Only. Credit Union pays Automatically.
	MemberPay Online Bill Payment

PLEASE DUPLICATE FORM FOR ADDITIONAL PAYEES By signing below, you acknowledge receipt of and agree to be bound by the terms contained in the Electronic Service Agreement, Account Agreement and Loan Agreement/Disclosure Statement applicable to my accounts and Parsons FCU Bill-Payment service. I understand that if I disclose my PARS Personal Identification Number (PIN) to anyone, they will have access to all accounts identified with my account number.
Payee Name
Address
City State Zip.
Dollar	Debit Date (1st, 2nd, Etc.)
Start Date
Financial (Electronic PYTS)
Institution
City State Zip
Account Number
Routing Number

Member Name	Phone Number	Account Number
Withdraw From (Checking ID)
Member Signature: X___________________________________________________ Date:_____________
Joint Owner Signature (If Applicable): X___________________________________________________ Date:_____________
		This credit union is federally insured by the National Credit Union Administration