MONTHLY CD STATEMENT AUTHORIZATION FORM Customer ... - gtsb [PDF]

State: ______ Zip: ______. Customer Authorized Signature. Date. By signing this form the customer agrees to pay $5.00 fo

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MONTHLY CD STATEMENT AUTHORIZATION FORM Customer Name _______________________________________ Account Number(s)_____________________________________

I/We the undersigned authorize Germantown Trust & Savings Bank to write statement information regarding our above listed account(s) to a CD-ROM. ? Please hold our CD Statement at GTSB-____________________. We will pick it up at that location. ? Please mail our CD Statement to the address below. We will inform the bank should this change, by requesting and filling out a new form.

Name: _________________________________ Address: _______________________________ City: ________________________ State: _______ Zip: ___________

Customer Authorized Signature ______________________________ Date _________________ By signing this form the customer agrees to pay $5.00 for every month that I receive a CD Statement, and request GTSB to debit account #__________ .

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MONTHLY CD STATEMENT AUTHORIZATION FORM Customer ... - gtsb [PDF]

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