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e-Statements Enrollment Form

(This information is for our records only.)
Full Name: New User: Current User Modification:

Business Name:

TIN/SSN: Primary Account Contact:

City: State: Zip:
Daytime Phone #: Alternate Phone #:  
E-mail Address:
Privacy Information: Drivers License #: State of Issuance:
Question:  What is Answer:
(List below all checking and/or savings accounts for which you are an owner and would like to receive an e-Statement. Within 1 business day we will acknowledge receipt of this request and send to you instructions for signing on to retrieve your e-StatementPlease note:  If you receive a combined statement, you only need to sign up for the leading account.)
Account # Account Alias
(as you identify this account)
1 (P)
(P) Indicates Primary Checking Account from which Log In information will be setup.
Account Type: C=Checking, S=Statement Savings (Passbook not available), R=Overdraft Protection Line of Credit, M=Mortgage Loan
BANK INFORMATION (To Be Completed By Bank)
New,  Date: _____________________________________________________
Existing, since  Date: _______________________________________________
CSR: ________ Officer Approval: ________ Branch: ________ Entered By: ________


(Please initial) 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 User Name and password to others. I understand that it is my responsibility to change my password periodically. I also understand the importance of regularly reviewing my account e-Statement(s) for any irregularities.

(Please initial) I understand that I am responsible for notifying the Bank if my email address changes.  In the event that my e-Statement notification is returned undeliverable, my statement will be mailed to the current postal address on file at the Bank and that my e-Statement service may be discontinued and any applicable service fees will be applied to my account.

(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.  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 clearly understand the Security Statement.

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