Online Enrollment Form

Each customer requesting online access should fill out an Enrollment Form and will receive a User ID.  A signed Enrollment Form must be submitted along with a signed Online Banking (Internet) Agreement to use the service.

PLEASE PRINT OR TYPE THE FOLLOWING INFORMATION

Name: Email:
Phone (Days): SSN or TIN:
Phone (Evenings): Birthdate:
Address: City/State/Zip:
Mothers Maiden Name: Temporary Password*:

Must be at least 8 characters-- You will be required to change this password when you first log on to the Service.
 

Online Banking (Internet) Access is provided FREE!  The BillPay service is free for the first three months.  Then the BillPay service is only $3.95 per month which includes up to 12 payments.  Each payment in excess of 12 per month will be an additional 40 cents.

Do you want the BillPay option?    _______Yes ________No

Which checking account do you want bills paid from? ______________________(This account will also be the account charged for the BillPay Service fee after the first 3 months.)

Do you agree to receive electronic notification at email address above? _____Yes ____ No

You will be given online access to all accounts on which you are listed as an owner and/or authorized signer.  If you would like to restrict online access to any of your accounts please list them here: 

_____________________________________________________________________

List accounts that you wish to restrict access through the Online Banking (Internet) Service:

Account Type* Account Number Account Type* Account Number
       
       
       
       

*Options include Checking, Savings, Certificates, IRAs, Loans (use back to list additional accounts)   

I have read and signed the Online Banking (Internet) Agreement and agree to the terms listed therein and herein.  I certify that I am authorized to sign on the accounts listed above.  I understand and agree that it is my responsibility to keep my password confidential to protect all my accounts.

Signature______________________________________        Date _________________            

Internal Use:   Port # _____________  Nameline _____  User ID ________________ Initial_____