Artesian City Federal Credit Union

NAME (Print)

________________________________________________________

ACCOUNT NUMBER

________________________________________________________

I herby authorize the credit union to debit my
account for the amount of $15 for a CD that
contains images of my cleared share drafts.

Viewer on CD for an additional $10

SIGNATURE

________________________________________________________

DATE

________________________________________________________

Fax:
229-888-3828

Mailing Address:
P.O. BOX 428
Albany, GA 31702-0428

You Must Print, Sign, and Return to Credit Union
print and mail or fax only.