First National Bank –
Jasper, TX
NetTellerä
Internet Banking Authorization Form
I (We) would like the First
National Bank of Jasper, Texas, to establish the following
person(s) as an Internet banking user for the indicated
account(s). I (We) understand that Internet access must be
carefully guarded and controlled. Security features such as
passwords and ID’s must be carefully safeguarded to insure
that no unauthorized access or transactions can occur. I (We)
understand that my (our) failure to safeguard passwords and
ID’s can result in transactions for which I (we) will be
held liable. I (We) also understand the increased importance of
reviewing my (our) bank statements and notices as soon as they
are received.
Important Note: If you have already signed up for basic
NetTeller™ account access and you want to either add
additional accounts or sign up for the Bill Pay feature, please
check this box. (_____)
| First Name | Middle | Last Name | E-mail Address |
| Address | City | State | Zip |
| Social Security Number | Primary Phone Number | Secondary Phone Number |
| Account Numbers You Wish to Access on NetTellerä | Transfer Funds From This Account? | Bill Payments From This Account? | What do you wish to call this Account? Car Loan, Household Checking, etc. |
Free Bill Pay Service________
Account Verification: _____________________(Mother’s Maiden Name, etc.)
All signatories on an account
must indicate approval for the above named person(s) to have
Internet access to the account(s).
____________________________________(Customer Signature) __________________ (Date)
____________________________________(Customer Signature) __________________ (Date)
For Institution use only: Institution personnel should initial and complete the following as applicable:
__________ (Initials) _________ (Date) The signature cards of the above accounts were reviewed and the customer is a proper signatory on the account.
__________ (Initials) _________ (Date) The customer’s accounts meet the institution’s standards to allow the customer to have Bill Payments.
__________ (Initials) _________ (Date) The customer’s accounts were entered onto NetTellerä
__________ (Initials) _________ (Date) The customer’s account was entered onto Bill Pay.
| NetTellerä ID Number: 7022 | Date Assigned: |
Fax to 409-384-6389 or Mail to First National Bank, P O Box 700, Jasper, TX 75951