• Please complete the following: All information will remain confidential.
Customer Information
*Indicates a Required Field
Date: 7/27/2021
First Name:*
Middle Initial:
Last Name:*
Business Name
(If Applicable)
State & Zip Code*  
Home Phone:*
Work Phone:*
Email Address:*
Date of Birth:*
Social Security Number:*
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, ect. 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
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. 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 by emailing Citizens Community Bank at ccb@citizenscommunitybank.com. You may receive one more printed statement before your online statements begin.