Power of Attorney

Power of Attorney
Authorizer Information (The one who gives the authorization)
Date of Authorization

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name Authorizer (The one who gives power of attorney)

First NameLast Name
Form of Identification the person who gives power of attorney
Authorizer Identification Card (sédula) Number
Identification card (sédula) number of the person who gives power of attorney
Authorizer passport Number
Passport number of the person who gives power of attorney
Member number
Information of the Authorized Representative (The one who receives the power of attorney)
Name of the Authorized Representative

First NameLast Name
Form of Identification of the authorized representative
Identification card (sédula) Number of Authorized Representative
Identification number of the authorized representative
Passport Number of Authorized Representative
Identification number of the authorized representative
Authorized representative to act on my behalve for * one time regarding my: *
Where the following will take place:
Select one of the options
Cash Withdrawal, in amount of XCG. *
Transfer, in amount of XCG. *to account * in name of *
Request and/or collect documentation (balance letter, interest letter, ACUito card and code, referral letter, bank statement, ACU e-Branch) for account: *
Change/Update member details *
Additional information of the authorized representative
Address

Street Name

Street Address Line 2

CityState / Province

Postal / Zip Code
House Number
for example: 12 óf 232B
E-mail
Authorized Representative E-mail
Phone Number
Required documentation:
- Valid identification of the authorized representative
- Address verification of the authorized representative (not older than 3 months)
- Valid identification of the member (copy)
Recipients mail 2
example@example.com
hidden field
Nomber Petishon
Submission Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty: