First National Bank – Jasper, TX
Internet Banking Authorization Form

I (We) would like the First National Bank of Jasper, Texas, to establish the following person(s) as an Internet banking user for the indicated account(s). I (We) understand that Internet access must be carefully guarded and controlled. Security features such as passwords and ID’s must be carefully safeguarded to insure that no unauthorized access or transactions can occur. I (We) understand that my (our) failure to safeguard passwords and ID’s can result in transactions for which I (we) will be held liable. I (We) also understand the increased importance of reviewing my (our) bank statements and notices as soon as they are received.
Important Note: If you have already signed up for basic NetTeller™ account access and you want to either add additional accounts or sign up for the Bill Pay feature, please check this box. (_____)

First Name Middle Last Name E-mail Address
Address City State Zip
Social Security Number Primary Phone Number Secondary Phone Number
Account Numbers You Wish to Access on NetTeller Transfer Funds From This Account? Bill Payments From This Account? What do you wish to call this Account? Car Loan, Household Checking, etc.

Free Bill Pay Service________ Account Verification: _____________________(Mother’s Maiden Name, etc.)
All signatories on an account must indicate approval for the above named person(s) to have Internet access to the account(s).

____________________________________(Customer Signature) __________________ (Date)

____________________________________(Customer Signature) __________________ (Date)

For Institution use only: Institution personnel should initial and complete the following as applicable:

__________ (Initials) _________ (Date) The signature cards of the above accounts were reviewed and the customer is a proper signatory on the account.

__________ (Initials) _________ (Date) The customer’s accounts meet the institution’s standards to allow the customer to have Bill Payments.

__________ (Initials) _________ (Date) The customer’s accounts were entered onto NetTeller

__________ (Initials) _________ (Date) The customer’s account was entered onto Bill Pay.

NetTeller ID Number: 7022 Date Assigned:

Fax to 409-384-6389 or Mail to First National Bank, P O Box 700, Jasper, TX 75951