Application

 


First Name Last Name Social Security #  
   
Mailing Address        
       
City   State Zip Code  
   
Telephone   E-mail Address    
   
Which type of NetTeller Internet Banking are you requesting?
 
Account Number   Account Type Account Description  
   
         
   
         
   
         
If you wish to have more than 3 accounts on NetTeller you will need to submit a second request listing the additional accounts
Bill Pay Customers
account number to debit by Bill Pay		    
       
Enter Mothers Maiden Name      
       
         
*      
         
         

* By submitting this application to First Bank of Carmi: (1) I/We will be bound by the terms and conditions of First Bank's (hereinafter Bank) Depository Agreement which may be amended at the Bank's discretion. (2) I understand that the password can be used to withdraw funds from the account(s) and that I must safeguard this code. I understand that I remain responsible for all activity on my account. All terms and conditions that were disclosed to me when I opened my account continue to apply. I also agree to hold the Bank harmless from any and all costs, suits, expenses, liabilities, damages, and attorney's fees arising from or related to the Bank acting in good faith in accordance with instructions of information that was sent electronically by the customer or the customer's authorized persons. (3) I authorize the Bank to disclose information about my account(s) to third parties in order to complete transactions using NetTeller. I also authorize my Payees to disclose to the Bank and its agents information regarding my account(s) with such Payee(s) in order to complete transactions using NetTeller, including to resolve questions regarding such transactions. (4)I agree that the Bank will not be liable to me if any unauthorized person intercepts electronic communications between myself and the Bank. (5) I must promptly report in writing any errors in connection with any NetTeller and / or Bill Pay service and any discrepancy between my records of orders and requests and the notice I receive from the Bank regarding the Bank's execution of my orders and requests. (6) I understand that the Bank will use the above e-mail address to periodically inform me of important bank information. (7) I agree that neither I nor the Bank shall be responsible for any loss or delay caused by any failure or interruption of any electronic communication system between myself and the Bank which are unavoidable or beyond either party's reasonable control. (8) I agree to pay the Bank the fees for placing stop payments and fees associated with the Bill Pay service if applicable. The Bank reserves the right to change fees and charges with advance customer notification. I understand that with the exception of placing stop payments and Bill Pay, all services accessed through NetTeller are provided free of charge. (9) If I fail to use my Netteller services for 180 days, my account will become dormant. Re-activation of my account will require the completion of a new Netteller application form. (10) If I fail to use my BillPay services for 60 days, the bank will automatically assess a service charge in the amount of $5.95 per month for this product. You must notify the bank to have this fee stopped and the BillPay account closed out.