RAPIDES GENERAL HOSPITAL EF CREDIT UNION
WESTERN UNION AUTHORIZATION FORM
DEADLINE FOR SUBMISSION 3:30 P.M.
MEMBER NAME
_________________________________________________________
MEMBER #
_________________________________________________________
AMOUNT
$ ______________________._________
ORIGINATOR FIRST NAME
_________________________________________________________
ORIGINATOR LAST NAME
_________________________________________________________
ORIGINATOR ADDRESS
_________________________________________________________
ORIGINATOR PHONE#
_________________________________________________________
RECIPIENT FIRST & MIDDLE NAME
_________________________________________________________
RECIPIENT LAST NAME
_________________________________________________________
TEST QUESTION (1)
_________________________________________________________
TEST ANSWER (1)
_________________________________________________________
PAYOUT LOCATION
CITY
_________________________________________________________
STATE
_________________________________________________________
ORIGINATING INSTITUTION
CATALYST CORPORATE FEDERAL CREDIT UNION
STATEMENT DESCRIPTION
_________________________________________________________
I UNDERSTAND THERE IS A $20 FEE FOR THIS SERVICE WHICH WILL BE DEDUCTED FROM MY ACCOUNT
MEMBER SIGNATURE
_________________________________________________________
DATE
_________________________________________________________
(1) For recipient to answer when picking up money at western union location (For security purposes)
FOR CREDIT UNION USE ONLY
279 WT FOR AMOUNT OF WU
DONE BY EMP INITIALS ___________________
279 FY WU FEE $20.00
DONE BY EMP INITIALS ___________________
Checked OFAC List - Sender and Receiver
Initials _____________ Date _____________________