Arizona Direct Deposit Form 3

25 S Arizona Place, Suite 111
Chandler, AZ 85225
Tel. (480) 831-2645
Toll Free: (800) 732-6986
Web: www.FirstCU.net
Direct Deposit Form
Please submit completed form to Originator’s Payroll/Accounting Dept.
Routing Number: 322172742
Direct Deposit Account Number
Deposit/Net Amount $
Personal (Receiver/Member)
Last Name
(Originator Name/Employer)
Suffix
Name
None
First Name
MI
Social Security #
Address
City
State
Zip
Arizona
Address
City
Contact Person
State
Zip
Contact Person Phone
Arizona
Home Phone
E-mail Address
Work Phone
Choose one of the following:
Start
Change
Cancel
I hereby authorize the above Originator to deduct from salaries, wages, or other dues in the amount specified above which are for
remittance to First Credit Union, 25 S. Arizona Pl. Ste. 111, Chandler, AZ 85225, for credit to my account.
___________________________________________
Signature
_______________
Date