Round Up Opt Out Form

Opt Out form for Round Up for Education

Member’s Name ________________________________________________________________

Address _______________________________________________________________________

Phone Number ______________________________________

Account Number(s) _____________________________________________________________

Please opt me out of the Round Up for Education Program. I understand and agree that by opting out of the program, no one in my immediate family can apply for scholarships funded by the program.

Signature ______________________________________________   Date __________________

Please mail this form to:          Member Services
                                                Pearl River Valley Electric Power Association
                                                P.O. Box 1217
                                                Columbia, MS 39429


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