ONLINE BANKING/BILL PAY APPLICATION

Name:________________________________________

Social Security No:______________________________          Mother's Maiden Name:____________________________

Address:______________________________________         

City:_________________________________________          State:_______          Zip Code:_______________________

E-mail Address:_________________________________

Home Phone #:_________________________________          Work Phone #:___________________________________

Please Choose one to indicate the accounts you would like to activate for online banking:

_____ All of my accounts

_____ Only the following accounts:

____________________           ____________________          _____________________          ____________________

____________________           ____________________          _____________________          ____________________

____________________           ____________________          _____________________          ____________________

_____ Online Banking and Transfer of Funds

_____Online Bill Payment

           I understand that there are monthly fees for this service and I authorize The First National Bank of Palmerton to charge my account

            for these fees.  Checking account number to be used for bill pay:_______________________

I certify that The information provided is true and correct.  I authorize The First National Bank of Palmerton to verify any information

included in this application.  I acknowledge receipt of  The First National Bank of Palmerton Online Banking Agreement and the Electronic

Funds  Transfer Disclosure.  I have read The First National Bank of Palmerton Online Banking Agreement and agree to the terms and

conditions of  The First National Bank of Palmerton Online Banking Agreement.

(signature)______________________________________                    (date)________________________

_________________________________________________________________________________________________________________

***bank use only***

Online Banking ID Number: __ __ __ __ __ __ __ __ __ __ __ __

ID Letter Sent:____________________                      Password Letter Sent:____________________