Peoples State Bank

To Apply, having already read and accepted account disclosures, simply complete and submit application. Peoples State Bank, will contact you with further instructions.

A representative from Peoples State Bank may contact you to verify your account application. Feel free to contact us with any questions you may have.

Check One: New NetTeller ID Existing NetTeller ID adding the Bill Pay Option.

SECTION A - APPLICANT INFORMATION

Last Name:

First Name:

Middle Initial:

Date of Birth:

Social Security Number:

Driver's License Number:

State Issued:

CIF Number (Optional):

Mailing Address :

City:

State:

Zip Code:

Email Address (optional):

Home Phone:

Work Phone:

Ext:

** ONLY put a CIF Number for an existing NetTeller ID if you are adding the Bill Pay Option.

SECTION B - BUSINESS INFORMATION

Business Name:

Tax ID Number:

CIF Number (Optional)

Mailing Address:

City:

State:

Zip Code:

Business Phone:

**ONLY put a CIF Number for an existing NetTeller ID if you are adding the Bill Pay Option.

SECTION C - ACCOUNT ACCESS

Please list the account number(s) the customer would like to access. List additional accounts on back of this app. Define the accounts by type. account types are as follows: Checking (D), Savings (S), Certificate of Deposit (T), Christmas (X), Loan (L), Overdraft Protection (O), and Credit Cards(R). Safety Deposit Boxes can not be accessed through Online Banking.

Account Number:

Type:

Primary Name on Account:

CIF Number:

Account Number:

Type:

Primary Name on Account:

CIF Number:

Account Number:

Type:

Primary Name on Account:

CIF Number:

Account Number:

Type:

Primary Name on Account:

CIF Number:

Account Number:

Type:

Primary Name on Account:

CIF Number:

Account Number:

Type:

Primary Name on Account:

CIF Number:

Account Number:

Type:

Primary Name on Account:

CIF Number:

Account Number:

Type:

Primary Name on Account:

CIF Number:

SECTION D - TYPE FULL NAME FOR AUTHORIZATION

Safety and Security Acknowledgement

As a user of this technology, it is my responsibility to take an active role in securing my data. I understand that I must safeguard my ID and PIN to ensure that only I have access to my financial information. You desire to subscribe to the services and authorize us, and any third party acting in our behalf, to serve as your agent in processing payment to targeted merchants and/or transferring to and from targeted accounts pursuant to your payment and/or transfer instructions, and you authorize us to post such payments and/or transfer to your designated account(s). You understand that we may not make certain payments and/or transfers if sufficient funds are not available in your designated account. This authorization is in force until revoked by you or us in writing and is subject to the Terms and Conditions as amended from time to time.

Yes, I would like to enroll in the Bill Pay Option Customer's Initials

No, I would like to enroll in the Bill Pay Option Customer's Initials

The customer MUST check one of the above boxes and he/she MUST INITIAL the appropriate line. Failure to comply may delay the processing of this application. Please note that Bill Pay may ONLY be done from a checking account.

Applicant Name:

Date:

BY CLICKING ON THE SUBMIT BUTTON BELOW, I APPLY FOR THE ONLINE BANKING ACCOUNT LISTED ABOVE AND CERTIFY THAT ALL INFORMATION PROVIDED ABOVE IS CORRECT AND AUTHORIZE YOU TO CHECK MY CREDIT AND VERIFY THE INFORMATION PROVIDED IN THIS APPLICATION. I ALSO CERTIFY UNDER PENALTY OF PERJURY THAT THE SOCIAL SECURITY NUMBER PROVIDED ABOVE IS CORRECT AND THAT I AM NOT SUBJECT TO BACKUP WITHHOLDING UNDER THE INTERNAL REVENUE CODE. I UNDERSTAND THAT ADDITIONAL INFORMATION MAY BE REQUIRED BEFORE A DECISION CAN BE MADE REGARDING THIS APPLICATION. I FURTHER UNDERSTAND THAT APPROVAL BY Peoples State Bank FOR ANY OF THE ONLINE PRODUCTS IS CONDITIONED ON MY AGREEMENT TO ABIDE BY ALL TERMS AND CONDITIONS CONTAINED IN THE APPLICABLE DEPOSIT AGREEMENT.

I HAVE READ THE ABOVE STATEMENT AND AGREE TO THE TERMS SET OUT THEREIN.

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