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”. |
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Access All Accounts |
List Accounts you wish to access |
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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 |
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Signatures on an account indicate
approval for the above named person to have Internet access to the
account. __________________________________________ (Customer Signature) _____________ (Date) For institution use only. Institution personnel should initial and complete the following as applicable:
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