Bill Payment Enrollment Form Please print this form out, complete, and either bring it by one of our offices, or fax to 214-357-3299, Attention: Home Banking Services. If you fax the Bill Payment Enrollment form to us please fax a copy of your driver's license as well. (Please print or type requested information)

Primary Member Number
Member Name
Member Address 1
Member Address 2
City, St, Zip Code
Social Security Number
Date of Birth
Daytime Telephone
Cell Telephone
E-mail Address

Request for Bill Payment Services submitted by:

                                                                                                                                 
                           Signature                                                             Date