P.O. Box 467, Port Jeff. Sta., NY 11776
Phone: (631) 476-6581 • Fax: (631) 476-3689
Secure Electronic Services Sign Up Form

This application refers to LICFCU’s Disclosure of information regarding Electronic Services.

Personal Account
First Name:
Middle Name or Initial:
Last Name:
Street Address:
Account Number:
Daytime Phone #:
Business Phone #:
Cell Phone #:
Email Address:
Joint Applicant:
First Name:
Middle Name or Initial:
Last Name:

Services Requested
Check the box of the service(s) for which you are applying:

Online Banking

E-Bill Payer

Remote Deposit

Do you have an Audio Response Pin? Yes No
Pick a Security Word:

By submitting below, I hereby apply to Long Island Community FCU to issue to me the confidential Personal Identification Number (PIN) indicated above for use with the Online Banking and E-Bill Pay (Checking Required); and, acknowledge that, I am responsible for the safekeeping of my PIN and all transactions by the use of the system. I understand that my PIN is not transferable; and, I will not disclose the PIN or permit any unauthorized uses thereof. However, if I disclose my PIN to anyone, I understand that I have given that person access to my account, via these systems; and, that I am responsible for any transactions conducted via same. I further agree to notify LICFCU immediately and send written confirmation if my PIN is disclosed to anyone who is not authorized to access or use my accounts. I understand that LICFCU reserves the right to discontinue access to these systems without notice and will not be liable for failure to honor transactions on these systems. I further understand that LICFCU reserves the right to implement charges for transactions on these systems. I understand that transactions are effective on my account at the time they are made; and, that the systems are available during the hours specified. I understand that the total dollar amount of transactions, via these systems, are subject to limits set by the Credit Union; and, sufficient verified funds must be available to satisfy my transaction instructions. All quoted balances are available balances and do not include items that have not cleared.

I agree to terms and conditions stated above. I have read the Disclosure of Information pertaining to LICFCU’s Electronic Funds System and agree to the rules and regulations disclosed herein; and, have obtained a copy of same.


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