Please complete the following:
All
information will remain confidential.
Customer
Information
*Indicates a Required
Field
Date:
<% = Date %>
First Name:*
Middle Initial:
Last Name:*
Business
Name
(If
Applicable)
Address:*
City:*
State & Zip Code*
,
Home Phone:*
(000-000-0000)
Work Phone:*
(000-000-0000)
Email Address:*
Date of Birth:*
(mm/dd/yyyy)
Social Security Number:*
(0123456789)
List below all accounts that you are a
signer on and would like to be able to have NetTeller access to. List
also the description you would like to use for each account you have
selected. Examples of some account descriptions you might like to use:
Checking, Savings, Car Loan, My Money, etc. No more than 20 letters or
numbers can be used.
Account
Number
Account
Description
Allow
Transfers
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Online Banking
Options
NetTeller
Citizens Community
Bank’s NetTeller allows me to use the internet to
transfer funds and make loan payments
between my accounts. I agree to the
following: Transfer requests may not
exceed the account’s available balance.
I will repay any overdraft that may
result from a transfer or payment
request. The maximum number of transfers
per month per cycle from an interest
bearing account may vary with the type
of account. I indemnify Citizens
Community Bank against
and from damages and liabilities arising
from any claim made against Citizens
Community Bank in
connection with complying with this
agreement. Citizens Community Bank may discontinue this
service without notice.
Citizens Bill Pay (NetTeller is
required)
I AUTHORIZE
Citizens Community Bank to post payment
transactions generated by Citizens Bill
Pay
to the account indicated below. I
understand that I am in full control of
my account. If at any time I decide to
discontinue this service, I will provide
written notification to Citizens
Community Bank. My use of Citizens Bill
Pay
signifies that I have read and accepted
all terms and conditions of Citizens
Bill Pay. Although payments are typically
received by the vendor within 3 business
days if made electronically and 5
business days if made by check, I
UNDERSTAND that payments may take up to
ten days to reach the vendor and that
they will be sent either electronically
or by check. My financial institution is
not liable for any loss or penalty that
I may incur due to lack of sufficient
funds or other conditions that may
prevent withdrawal of funds from my
account. If I am
paying bills from more than one of my
checking accounts, I understand that I
will be billed only once per month for
the service and that the monthly fee
will be deducted from my checking
account with the lowest number. Citizens
Community Bank
reserves the right to cancel your
Citizens Bill Pay service at anytime for the
improper handling of your Citizens Bill
Pay
account.
Please
provide the checking account number
that you would like to
pay bills from.
Online Statement (NetTeller is
required)
I authorize
Citizens Community Bank to provide an electronic
monthly statement, and any other
additional correspondence that may be
required involving the status of any account(s) that I am the primary
accountholder. Additionally, I authorize
Citizens Community Bank to provide an electronic privacy
disclosure through my Online Account. I
understand that I will need a personal
computer, an operating system and
telecommunications connection to the
Internet as well as Adobe Acrobat Reader
to access and retain the electronic
statements. The supported browsers are:
Microsoft Internet Explorer version 7.0
and Firefox Version 3 & higher. I
understand that I will no longer receive
a copy of my statement, Citizens
Community Bank’s
privacy disclosure, or any other
correspondence regarding these account(s)
in the mail. I understand that each
month, on my statement cycle date,
Citizens Community Bank will send me an
email notifying me that my statement is
available for viewing on NetTeller at
www.CitizensCommunityBank. I understand that I
have the ability to retain a copy of my
electronic statement and Privacy Pledge
by printing it. I also have the ability
to save a copy of my statement to my
hard drive, a disk, CD, etc. I also
understand that my electronic statement
will be available for viewing or
downloading for one year after the
statement cycle date and that it is my
responsibility to notify Citizens
Community Bank of any changes to my email
address. By submitting this form, I
understand that I am obligated to review
my statement for errors and omissions.
Please refer to your account
disclosures for specific rules and
regulations regarding your obligations.
(Account disclosures are available upon
request.) To request a paper copy of
your statement, switch from electronic
statements to paper statements, or
update your email address, contact
Citizens Community Bank by calling
618/566-8800, or emailing Citizens
Community Bank at . There is a fee to obtain a paper copy of your statement. You
may receive one more printed statement
before your online statements begin.
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