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 Electronic
Bill Payment
Subscriber Enrollment Form
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Important: Please complete the
form below, (you can complete it online first then print it or print it
first then complete it using block letters) and return it by mail to
your financial institution at:
Hopewell Valley Community Bank
Attn: Electronic Bill Payment Dept.
Post Office Box 999
Pennington, New Jersey 08534
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APPLICANT |
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Security and Access |
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Social Security Number
(to be used as your confidential
Subscriber ID) |
Mother's Maiden Name
(for security)
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Date of Birth
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Personal Information Must
be valid U.S. address and telephone numbers |
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First Name
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Middle Initial |
Last Name |
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Address
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City
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State
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Zip Code
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Daytime Telephone Number
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Evening Telephone Number
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Fax Number
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Email Address
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ACCOUNT
INFORMATION
Account From
Which Your Authorized Bill Payments & Service Fees Will Be Debited |
Routing & Transit
Number
031207827
(to be validated by
your financial institution) |
Account Number
(to be validated by
your financial institution) |
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SERVICE
INFORMATION |
Hopewell Valley Community Bank WBP31 Product
Code 000 Fulfillment Code 505 Billing
Class
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I authorize my financial institution
to debit the account indicated above for payments I request through
CheckFree and for the appropriate monthly bill payment service fee. I
understand that the service fee will be debited monthly from the account
designated above until I provide written notification to CheckFree to
cancel the account. My first use of the service signifies that I have
read and accepted all of the terms and conditions of the CheckFree
service. |
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Applicant Signature
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Date
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CheckFree must have
your signature on this form in order to process the information. |