Account Number: _________________________________________________

Name: __________________________________________________________

Home Address: ___________________________________________________________________

City: ____________________________________________ State: _________ Zip Code: ________

Home Phone: _____________________________ Work Phone: ____________________________

Email Address (required): ___________________________________________________________

AUTHORIZATION

By signing below, I am applying for SELCCU Internet Services. Should you approve my application, I agree that my use of SELCCU Internet Services will be governed by all SELCCU Account Agreements, Disclosures, and Fee Schedules, as well as the SELCCU Internet Services Agreement and Disclosure Statement. I understand that my password is issued for security purposes to authenticate electronic transfers and withdrawals. It is my responsibility to safeguard my password. I understand that if I disclose my password to any non-owner, I am fully responsible for transactions performed on my accounts. By signing this application, I expressly agree that you may send any required disclosures or information to me by electronic communication. Information submitted will be verified against our membership records on file. Discrepancies in the information provided above will cause your application for SELCCU Internet Services to be rejected.

Your SELCCU Online PASSWORD needs to be a five to eight digit set of letters and/or numbers known only to you. We highly recommend using both letters and numbers. Please do not choose any part of your name, address, Social Security Number, or date of birth. When you log on to any SELCCU Internet Service, you will be asked to enter your password. You will be able to log on only if your password is entered correctly. This is an important safety feature. No one else can log on to your account unless they know your password! Please choose a SELCCU Online Password and write it in the box below. Then, record this password somewhere safe where you can refer to it in case you forget. Don’t keep it with your account number. If applying for E-Statements, you will be assigned a password, which will be e-mailed to you.

Once entered into our system, this portion of the application is shredded and unavailable to anyone. Password: ________________________________________________________                (Choose a password that is 5 to 8 digits and/or letters) Your E-Statements password will be assigned to you and sent with your E-Statements confirmation notice.

School Employees Lorain County Credit Union, Inc. 340 Griswold Rd. Elyria OH 44035   www.selccu.org memberservices@selccu.org 440-324-3400 or Toll Free 1-800-451-6315