AUTO EXCHANGE

CHECK WRITING PRIVILEGES REQUEST FORM

_________________________________ WISHES TO ESTABLISH CHECK WRITING PRIVILEGES WITH AUTO EXCHANGE.  THEY HAVE A CHECKING ACCOUNT WITH YOUR BANK ___________________________, UNDER ACCOUNT # __________________________.  AUTO EXCHANGE REQUIRES THE FOLLOWING INFORMATION:

1)      DATE ACCOUNT OPENED: ____________________

2)      AVERAGE DAILY BALANCE: ____________________

3)      NUMBER OF OVERDRAFTS OR NON SUFFICIENT FUNDS CHECKS IN THE LAST YEAR: ____________________

I, _________________________ GIVE MY PERMISSION TO RELEASE THIS INFORMATION.

_______________________________________________ _______________________

(ACCOUNT HOLDER)                                                                                        (DATE SIGNED)

_______________________________________________  _______________________

(BANK PRINT NAME)                                                                                       (DATE SIGNED)

___________________________________________ __________________________________________

(BANK SIGN NAME)                                                                         (TELEPHONE NUMBER & EXT)

BANK STAMP REQUIRED ON THIS FORM

Box 23 · Jernee Mill Road · Sayreville, N.J. 08872· (732) 238-4006·Fax (732) 238-9821