Bill Pay Registration Form 
Mail:  PO Box 64630, Baton Rouge, LA  70896
Fax:  225-927-1960

Name___________________________________________________

Joint Owner Name_________________________________________

Address__________________________________________________

City_________________________ State____ Zip________________

Home Phone  (_____)_______________________________________

Daytime Phone  (_____)_____________________________________

E-Mail (required)___________________________________________

Social Security Number_____________________________________
 
Checking Account Number: 0 0 9 0 ____________________________

By signing below I certify the above information to be true and correct.  I understand that when I begin to use Eagle Federal’s Bill Pay it means that I understand the disclosure statement which accompanies this form and agree to all terms and conditions found in the current master account agreements as they may be revised from time to time. 

Member Signature

_________________________________________ Date____________

Disclosure
I understand that my PIN is issued for security purposes to authenticate electronic transfers and that I am responsible for safeguarding my PIN. I understand that in disclosing my PIN to anyone, I am providing that person with the authority to perform all transactions relating to my account(s) until I revoke that authority by changing the PIN.

I authorize Eagle Federal to charge my checking account for any fees incurred associated with using Bill Pay.  I authorize Eagle Federal to withdraw payment transactions to be remitted to the payee and account I have indicated.  I understand that I am in full control of my account and once begun, any recurring payments I have initiated will continue until such time as I specifically cancel those payments.  I understand that payments may take up to five days to reach the vendor and that they will be sent either electronically or by check.  Eagle Federal is not liable for any service fees or late charges levied against me.