Spring Mill Employees FCU

Spring Mill Employees FCU

Internet Flexteller Enrollment Form

Member Name	Joint Owner Name
Member SSN	Joint Owner SSN
Member Date of Birth	Joint Owner Date of Birth
Street Address	City, State and Zip Code
Home Phone Number	Email Address (Optional)

Base Account Number _______ FREE Internet Flexteller Services - Unlimited Use

Security Question: Please select on the questions below and provide the answer. This information will be used in the event we need to verify your identity over the phone.

_________ 1. Name of your first born child? ______________________________________

_________ 2. In what city were you born? ______________________________________

_________ 3. What is your mother’s maiden name? ______________________________________

X_________________________________________ ______________________________________

Signature of Primary Member Today’s Date

Accepted By (MSR) and Date