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Getting Started

On-Line Order Form for
ETASM Enrollment Kit

The ETA enrollment kit includes all materials necessary for a financial institution to become an ETA provider. Please complete the following form to receive an ETA enrollment kit.� You may also print the form and fax it to (214) 922-6778. In addition, financial institutions may call 1-888-ETA-FRBK (382-3725) for more information about enrolling in the ETA program.

Please send me an ETA enrollment kit:

Name:
Title:
Financial Institution:
�
ABA Routing Number:
Address:
City/State/Zip:
Phone:
Fax:
E-mail:

�
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