CUSTOMER INFORMATION
| Name: _____________________________New User [ ] Existing User Modification [ ] |
| Address: _______________________________ TIN/SSN: ________________ |
| City: __________________________ State: ____________ Zip: ____________ |
Primary Contact for Account(s):
Email Address: _____________________________
REQUESTED SERVICES
[ ] Account Access (history/transfers)ACCOUNT INFORMATION
| Account # Account Description (as you identify this account) Type |
| 1. _______________ (P)_________________________________ ____________ |
| 2. _______________ _________________________________ ____________ |
| 3. _______________ _________________________________ ____________ |
| 4. _______________ _________________________________ ____________ |
| 5. _______________ _________________________________ ____________ |
| 6. _______________ _________________________________ ____________ |
| 7. _______________ _________________________________ ____________ |
(P) Indicates Primary Checking
Account from which charges you incur will be debited. USER INFORMATION – (REQUIRED TO ACTIVATE YOUR ACCOUNT) All account owners or authorized signers must sign below. USER INFORMATION (To Be Completed by Bank)
[ ] New Date:
_______________________________________________________
Account type: CH = Checking
MMA= Money Market SAV= Savings RLOC= Revolving Line of Credit
IL= Installment Loan
User Name
Account # (S)
List all
users you authorize to utilize ONLINE BANKING
ALL is appropriate if
you will have FULL privileges on ALL accounts.
I/We understand that submission of this form only constitutes
application for enrollment in the Services. I/We have read the
Agreement and Electronic Funds Transfer Disclosure for Internet
Banking Service and the terms are acceptable to me. I/We
understand that the Bank may, at its sole discretion, request
for additional documentation from me/us to complete this
enrollment process.
SIGNATURES: By signing below, I/We authorize THE BANK to issue a
temporary password on my/our behalf which I/We will be forced to change
to a private password the first time I/We log in to the system.
________________ _______
________________ _______
Signature Date Signature Date
________________ _______
________________ _______
Signature Date Signature Date
________________ _______
________________ _______
Signature Date Signature Date
CUSTOMER INFORMATION
[ ] Existing since: Date
_______________________________________________
Officer:
Branch:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Request
Received by: _________
Processing Officer: ___________ Date Processed:_______
Line # ______________ Reviewing Officer: ____________ Date Reviewed: _______
Portfolio # _____________Date
Packet Mailed: _________ Mailed by: _________