Certegy Check Services, Inc.

VIP Enrollment Form

To enroll, print out this form, complete and sign. Mail it to the address listed below. Be sure to include a copy of your
government issued identification. If requesting VIP for check writing, include a voided check.

Order by Mail Certegy Check Services, Inc.

Attention Certegy VIP
PO Box 30046
Tampa, FL 33630-3046

Please indicate if you are requesting VIP enrollment for: Check Writing* Check Cashing**

Required for all VIP enrollments

Individual Information: For consumers and sole proprietors only. Please Use Capital Letters Only
First N Last N MI
Home Ph#: ( )- - Cell Ph#: ( ) - -
Street Add: Apt/Unit #:
City: St: Zip: -

Government-Issued Identification: State: #

Exp. Date: (mm/dd/yyyy) Date of Birth:

*This section is required to be placed on VIP for Checking Writing (include a voided check)

Banking Information: (You must include a blank check with "VOID" written across it for each checking account listed.)
Routing # of Your Financial Institution: Account #:
Account Type: Checking Money Market Other

Name of financial institution:

**This is required for Check Cashing Only

Social Security Number - -

This enrollment form is the sole property of Certegy Check Services, Inc. (“Certegy”). It is understood that we will verify the above
information to determine eligibility. Upon eligibility, you will remain in the Certegy VIP Program for thirteen months. Certegy reserves the
right to remove you from the Certegy VIP Program if one or more of your checks are dishonored.

Your name: (please print) Your signature: Date: