First State Bank  
Livingston, Texas  77351 - (936) 327-5211
  INTERNET BANKING AUTHORIZATION FORM

I (We) would like the institution to establish the following person as an Internet banking user for the indicated account(s). I (We) understand that Internet access must be carefully guarded and controlled. Security features such as passwords must be carefully safeguarded to insure that no unauthorized access or transactions can occur. I (We) understand that my (our) failure to safeguard passwords can result in transactions which I (we) will be held liable for. I (We) also understand the increased importance of reviewing my (our) banking statements and notices as soon as received.

Name: 2nd Name:
   SSN:  SSN: E-Mail:
 Address  City  State  ZIP
Primary Phone   Sec. Phone
 
Internet Banking Bill Payment 
Access account balances, transfer money, and conduct common banking tasks on-line. You may sign up for “Bill Payment” online.  Once you access NetTeller TM!, click “Bill Payment” in the top menu bar.  Click “Add Account”.  Then select the account from the drop down box that you want to pay bills from and submit.  Choose the check number you want the bill payment checks to begin with from the drop down box.  Please read the disclosures and click “Accept” or “Decline”.
 

Access All Accounts

List Accounts you wish to access

Account Numbers You Wish to Access on NetTeller

Transfer Funds From This Account?

What do you wish to call this account? i.e. Car Loan, Household Checking, etc.

YesNo
YesNo
YesNo
YesNo

Signatures on an account indicate approval for the above named person to have Internet access to the account.
__________________________________________ (Customer Signature) _____________ (Date)

__________________________________________ (Customer Signature) _____________ (Date)

For institution use only. Institution personnel should initial and complete the following as applicable:

The signature cards of the above accounts were reviewed and the customer is a proper 
signatory on the account.
 (Initials)____________
The customer’s accounts were entered onto NetTeller.  (Initials)____________
Billing Plan:_____________________                     NetTeller I.D. Number: 7021                                        Date:   ____________