Secure Online Account Enrollment Form 5675 Highway 18 West, Jackson MS 39215-1403 Phone: 601.922.7055  •  Fax: 601.922.3283

Member Account Number: First Name: Middle Name/Initial: Last Name: Street Address: City: State: Zip Code: Select.......... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Home Phone #: Cell Phone #: Work Phone # Ext: Last 4 Digits Of Social Security #: Birthdate (MM/DD/YYYY): Email Address: Please make sure that the information in this form is the same as what you have provided the credit union. If you are unsure about what address or phone number is on file at JAFCU please contact a Home Banking representative at 601.922.7055 OPTION 3 for further assistance.