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ENROLLMENT FORM


CUSTOMER INFORMATION:
(This information is for our records only.
You may need to enter this or more information upon entering Online Banking.)
Full Name: New User: Existing User Modification:
Address: TIN/SSN:
City: State: Zip:
Phone: Primary Contact for Account(s):
E-mail Address:
Privacy Information: Drivers License#: State of Issuance:
Question:  What is Answer:
REQUESTED SERVICES
Account Access Only - Remove from Bill Pay
(history/transfers)
Bill Payment
(Must have a checking account. Subject to credit approval.1)
e-Statements
(paper statements will not be mailed)
 
USER INFORMATION - (REQUIRED TO ACTIVATE YOUR ACCOUNT)
Account # Account Description
(as you identify this account)
Type Flag
1 (P)
2
3
4
5
6
(P) Indicates Primary Checking Account from which charges you incur will be debited.
Account Type: CH=Checking, MMA=Money Market, SAV=Savings, RLOC=Revolving Line of Credit,
IL=Installment Loan
Flag: D=Deposit Only, F=Full Rights, V=View Only; NO transfers permitted
BANK INFORMATION (To Be Completed By Bank)
CUSTOMER INFORMATION
New  Date: _____________________________________________________
Existing, since  Date: _______________________________________________
CSR: ________ Officer Approval: ________ Branch: ________ Entered By: ________



SIGNATURES: By submitting below, I authorize Unified Bank division to issue a temporary password on my behalf which I will be required to change to a private password the first time I log in to the system. Further, I understand the importance of maintaining password confidentiality and I will not disclose my Login ID and password to others. I also understand the importance of regularly reviewing my account statement(s) for any irregularities.

(Please initial) I certify that everything I have stated in the Enrollment Form and on any attachment is correct. You may keep this form whether or not it is approved.

(Please initial) 1 I have chosen Bill Pay. By submitting below, I understand that transactions paid with a paper draft normally take between 5-10 business days to complete and those transactions paid electronically are normally completed within 3 business days. Further, I understand that online bill payment is provided to me for my convenience.  The actual payment of such bills is handled by an independent third party, Fiserv CheckFree, or a future succeeding company, and Unified Bank, its affiliates, and its divisions cannot and will not guarantee or be held responsible for the completion and accuracy of such transactions.

(Please initial) By choosing to receive e-Statements, I understand that I will no longer receive a paper statement sent through the U.S. Postal Service and that I am responsible for viewing and printing or savings my e-Statements for my historical record keeping.

(Please initial) I certify that I have read and understand the Security Statement.

(Please initial) I certify that I have read and understand the Privacy Notice.