LAPEER COUNTY SCHOOL EMPLOYEES CREDIT UNION

168 N. Saginaw Street, PO Box 425, Lapeer, Michigan, 48446

Last Name____________________________First_____________________Initial__________

Address_____________________________________________________________________

City_______________________Zip__________________Phone________________________

School District Name ___________________ School Name________________________

Your Classification________________________________

PLEASE DEDUCT FROM EACH PAY $ _______________________

To apply as follows:

Shares 61______________________

Christmas Club_________________

Drafts____________________________