Bank VI NetTeller
Online Banking/Bill Pay
Enrollment Form

 

 

Instructions:  Print and complete this form, sign it, and bring it with picture ID to:

1900 South OhioSilver at Main Street

Salina, Kansas††††† Geneseo, Kansas

 

We will establish your Bank VI NetTeller service and contact you with instructions for sign-on.

 


 

 

 

 

Email Address:  (required)*     _____________________  Date: ______________________

 

 

 

Are you currently a Bank VI NetTeller Customer?  Yes____   No____

 


 

 

 

 

 

Name 1:  ________________________________†††

 

 

Social Security/ ID Number 1: ______________________ 

 

 

 

Date of Birth____________________

 

Drivers License Number or Government Approved ID (attach photocopy):____________________

 

 

Name 2:  _________________________________

 

 

Social Security/ ID Number 2: _______________________

 

Date of Birth _____________________

Driverís License Number or Government Approved ID (attach photocopy):____________________

 

 

 

Note:  P O Box holders must furnish a physical address as well as a mailing address!

 

 

 

 

 

Residential/Business Address:______________________________________ 

 

 

 

City: _______________________ State: _____________Zip Code: ___________________ 

 

 

 

Mailing Address (if different from above)_______________________________ 

 

 

 

City: _______________________ State: _____________Zip Code: _____________              

 

 

 

Identifying question for account:

 

Motherís Maiden Name ___________________          

 

City in which you were born: ___________________________

 

 

 

Home Phone #____________________†† Alternate Phone #___________________

 


 

 

Please access the following accounts:     

 

 

 

Account Number

††††††††††† Account Type

 

 

 

 

 

 

 

 

 

 

 

 

 

Bill Pay Enrollment

 

 

All Checking Accounts will be accessible for Bill Pay.

 

 

  Bill Pay    $4.95 per month with 10 free items; additional items are $.40

 

each.Charge the following account: __________________________

 

 


 

 

 

 

Please Read Before Signing - I certify that the information provided is true and correct and that I am the owner of these accounts or the duly authorized representative of the owner and authorized to act for the owner. I authorize Bank VI to verify any information by credit check, prior banking activity, employment history, and/or other information should it deem necessary to confirm my identify and evaluate by account status in compliance with the USA PATRIOT Act and related laws and regulations and to allow access to all accounts listed above. I have received and agree to the terms and conditions of the NetTeller Services Agreement and such other terms and conditions or amendments thereto, as may be established by Bank VI and communicated to me. I agree not to allow anyone to gain access to the services using my Password or to let anyone know my Password. I accept all responsibility for all transactions initiated under my login ID and Password, up to the limits allowed by applicable law.

 

 

 

Bill Payment - I understand that I will be responsible for determining the payee of such payments, scheduled pay date, account to be used for bill payments, and the availability of funds in my account. I understand that any payment made without sufficient funds in my account will be returned and my account will be charged an overdraft fee. I also understand that bill payment may take the form of a check and may take up to ten (10) days to reach the payee. Bank VI is not liable for late charges or other penalties associated with late receipt of payment by the payee. I authorize Bank VI to debit my account for all bill payment fees. If at any time I desire to discontinue bill pay, I may do so upon written notification to:

Bank VI, 1900 South Ohio, P.O. Box 77, Salina, Kansas67402-0077

 

 

 

 

 

Signature:  __________________________________________

 

Date: _______________

 

 

Signature†† __________________________________________

 

Date:_______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Member FDIC†††††††††† An Equal Housing Lender