Online Banking Enrollment Form

First Name:
Middle Name:
Last Name:
Email Address:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Daytime Phone:
Evening Phone:
Mobile Phone:
Fax Number:
Date of Birth:
Drivers License #:
Security Question:
Security Answer:
Account Information
Please provide the Account Type and the Account Number for each account that will be accessed using Online Banking. Please note all accounts(s) must have the same ownership as the individuals(s) indicated above.
Account Type: ____________________ Account #: ________________________
Account Type: ____________________ Account #: ________________________
Account Type: ____________________ Account #: ________________________
Account Type: ____________________ Account #: ________________________


ONLINE BANKING TERMS AND CONDITIONS AGREEMENT
I (We, if joint account holder) have reviewed the "Online Banking Terms and Conditions Agreement" for First Central Bank, Online Banking Service and Optional Bill Payment Service and accept such Online Banking Terms and Conditions Agreement. By using the online financial services provided by First Central Bank, I / We agree to abide by the terms and conditions of this agreement. I/We hereby authorize First Central Bank, to charge the primary account indicated above each month for the appropriate fee amount as outlined in the Online Banking Terms and Conditions Agreement.

Online Bill Payment service will be free to customers maintaining 3 or more qualifying accounts with First Central Bank. Qualifying accounts are classified as Checking, Savings, Christmas Clubs, CD’s, Loans, or Safe Deposit Boxes. Those customers who do not maintain 3 or more qualifying accounts will incur a fee of $6.95 per month plus $.50 per payment after the first 15 payments for Bill Payment Services.

 

Signature-Primary Account Owner/Signer:

 __________________________ Date: __________

 

Signature-Joint Account Owner/Signer:

 __________________________ Date: __________




Yes, I agree to use Bill Pay and accept the fees as stated.


No, I do not wish to use Bill Pay.
 
Return Enrollment Form to First Central Bank of Mail To:

Mailing address:   P.O. Box 340
                             Philippi, West Virginia  26416
                             Fax: (304) 457-3647