Processed by National Payment Card

Payment Card Enrollment Application

Please complete the following information and click Submit (All fields are required)

First Name:

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Last Name:

Street Address:

City:

State:

Zip Code:

Phone (XXX-XXX-XXXX):

Email Address:

Drivers License Number:

Why do you need my drivers license?

Confirm/Re-enter Drivers License Number:

State Issued:

Year Issued(YY):

Birth Date (MM/DD/YYYY):

Payment Card Number:

Confirm/Re-enter Card Number:

Click here for additional cards on same account

Use the image on the left to guide you in entering the bank routing number and checking account number information in the fields that follow.

Do not use a savings account or a prepaid debit checking account.

Bank Routing (ABA) Number:

Checking Account Number:

Click here for helpful bank and PIN information

Personal Identification Number (PIN)/UserID:

Confirm/Re-Enter your PIN/UserID:

Security Question:

Answer:

Authorization: By checking this box and submitting this information, I confirm that I am at least 18 years old and have read and agree to the Enrollment Terms and Conditions. I authorize National Payment Card Association to debit or credit the enrolled account that I use with my payment card. I authorize the listed payee (Eggens Direct Service), when the payment card is used for purchases, to debit my account for the amount indicated in the tender amount of my payment transaction. In the unlikely event this transaction (for the amount tendered) is returned unpaid, I agree that a return fee will be collected by the same electronic means mirroring fines permitted by State laws.
NOTE: You may also incur separate fees from your Financial Institution (Bank) for returned transactions. Because of this, we highly recommend that you have Overdraft Protection on your checking account to avoid additional return fees when using this card.

I acknowledge that I have voluntarily provided certain information to National Payment Card Association in order to participate in this program. I further acknowledge that, by authorizing this enrollment, the checking account that I am providing has sufficient funds that will not allow the bank validation process to go negative and that the account is owned by me and is a valid account to transact business in the USA.

All fields are required.