Application for Creighton Federal's Pre-Authorized VISA Payment

Please complete this form, then print, and sign. Your signature (s) are required.
You can either mail this form to:
Creighton Federal Credit Union
2575 Dodge Street
Omaha, NE 68131-2602
or bring it in to any of our five convenient Creighton Federal offices.

(All Fields Below Must Be Completed)

I (we) hereby authorize Creighton Federal Credit Union to initiate withdrawals from the depository and account indicated below
to pay my (our) Creighton Federal Credit Union VISA credit card. Payment will be made approximately 10 days after your statement closing date.

Creighton Federal Visa Credit Card Account Number
Depository Name
Depository City, State
Transit/ABA No.
Your Account # with Depository Savings Checking

The amount of the payment to be deducted monthly is:
(Please Check One Of The Following)
The Minimum Payment
The Total New Balance Due
A Fixed percentage of the New Balance due of (Must be greater than 3%)
This authority is to remain in full force until Creighton Federal Credit Union has received written notification from me (us) of its
change or termination, which must be at least 30 days before the effective date of any change or termination.

I (we) further understand and agree that Creighton Federal Credit Union shall not be responsible for any act or failure to act
except in the case of gross negligence or willful misconduct. Furthermore, I (we) agree to hold Creighton Federal Credit Union
harmless for any claims, liability, costs, and expenses in the execution of the agreement.
Signature
Name (Print)
Date
Signature
Name (Print)
Date
Your request to have your payment automatically made from your checking or savings account will be processed.
It may take up to 60 days or two statement cycles. Continue to make regular monthly payments until you receive a message
on your VISA statement that reflects the dollar amount and date your automatic payment will begin.