ONLINE BANKING APLICATION
Taken by: Initials Extension
CUSTOMER INFORMATION
Name: New User Existing User Modification
Address: TIN/SSN:
City: State: Zip:
Home Phone: Primary Contact for Account(s):
Work Phone: E-mail Address:
ACCOUNT INFORMATION
Account Authorization Level Account Name
List all the accounts you wish to have access to for Citizens Online Banking.
Account No.
List corresponding Account Numbers.
VIEW ONLY
Account may be viewed only.
No transactions or services.
DEPOSIT ONLY
May deposit into the
account ONLY.
FULL
Full authorization provides
FULL rights to the account.
Enroll me in E-Statements for the accounts listed (I understand that I will no longer receive paper statements)
CITIZENS BANK INFORMATION (TO BE COMPLETED BY BANK)
New Date: Existing, since:
Online Banking ID Number:
Officer: Branch:
Comments:
Signatures: By signing below I authorize Citizens Bank to issue a temporary password on my behalf which I will be required to change to a private password the first time I login to the system. I understand that access to the system is governed by the Online Access Agreement and Electronic Funds Transfer Disclosure, a copy of which I have received, and I agree to its terms.
Signature Date Signature Date
Signature Date Signature Date
*
New Online Banking accounts and changes made to any Online Banking accounts, can only be made by an authorized signer on said account.
Please FAX completed form to: 575-523-8625