Here you go:
Branch Address Information here
In order to provide you by fax with valuable information concerning our products and services, such as current rates of interest (due to a change in regulatory policy issued by the Federal Trade Commission), you must agree to the following:
________________________________ gives us permission to fax us
(Your company name)
information at fax number(s) ___________________________ __________________________.
You may return this to me at the address above, in the enclosed self-addressed, stamped envelope.