Please list all accounts that need to be activated for online banking. After you have completed the application, please
sign the application. If you have any questions, please call 641-648-2544 and ask for the bookkeeping department.
Account #
Type (C, S, L, CD)
Account #
Checking, Savings, Loan, Cert. of Deposit
Type (C, S, L, CD)
________________________
___________________________
________________________
___________________________
________________________
___________________________
________________________
___________________________
First Name _________________________ Last Name ____________________________
Spouse
_____________________
E-mail Address ___________________________________________________________
Address ________________________________________________________________
City
____________________________ State & Zip Code ________________________
Home Telephone _____________________ Work Telephone _______________________
Social Security Number/Tax ID _____________________
Date of Birth___________________________ Place of Birth _______________________
Mother’s Maiden Name ____________________________
I certify that the information I have provided is correct to the best of my knowledge.
CUSTOMER SIGNATURE ________________________________ DATE ________________
FOR BANK PURPOSES ONLY
Accounts Verified By ____________________________
Customer Service Representative ___________________
Date Entered on Internet Banking __________________
User ID ______________________________________
Password ___________________________________
Bill Pay__________