PRIMARY ACCOUNT HOLDER CUSTOMER INFORMATION:

Last Name:
First Name:
Middle Init:
Address:
City:
State:
Zip Code:
Social Security #:
Mother's Maiden Name: (For security purposes)
Home Phone:
Work Phone:
E-Mail Address:
Date of Birth:

TERMS and CONDITIONS:
I/WE understand that all account holders have their own User Identification Numbers and Passwords that enable them to use this service. I/We are responsible for the confidentially and use of our Passwords. I/WE agree to change the Password if at anytime I/WE believe that the Password has been compromised. I/WE understand that if I am a joint account holder, all account holders on that joint account may have access to the joint account information. The Bank is hereby authorized to debit and credit my/our accounts in processing my/our request to transfer funds. I/We agree to request transfers only against accounts with sufficient available balances, and further understand that I/WE are responsible for any overdrafts created because of a request for an electronic transfer. The Bank reserves the right to revoke this online banking service at any time without any prior notice required.

ACCEPTANCE:
By signing this application, the undersigned agree to abide and be bound by the terms of the Truth In Savings and Electronic Funds Transfer disclosures, and the Online Banking and Bill Pay Terms and Conditions. Further, the undersigned acknowledge receipt of a copy these disclosures along with a copy of the terms and conditions.

ALL ACCOUNT OWNERS MUST SIGN THIS APPLICATION.

Sign me up for:
Online Banking Only	Online Banking with Bill Pay By using United Savings Bank online banking and bill payment service you agree to the terms and conditions.

If Bill Pay is selected please supply your checking account number Checking account number

I am a current Online Banking customer I am a current Bill Pay by phone customer

Signature (Primary)		Date
Signature (Joint)		Date

	FOR BANK USE ONLY: Rec'd_______________   Contact By EM/PH _______________ PIN SETUP ______________