Community Bank Wheaton / Glen Ellyn - On-Line Banking Application

357 Roosevelt Road - Glen Ellyn
100 North Wheaton Avenue - Wheaton
370 South County Farm Road - Wheaton

ON-LINE BANKING APPLICATION

	On-Line Banking Only
	On-Line Banking & Bill Payment	Checking Account Number for Bill Payment

Applicant
	Last Name
	First Name
	Title
	Home Address

	City, State, Zip
	Home Phone
	Home Phone	(include area code)
	Work Phone	Ext.
	Work Phone	(include area code)
	Fax Number
	Fax Number
	Unique Identifier
	Unique Identifier	(Mother's Maiden Name)
	S.S. Number
	E-mail Address

Co-Applicant
	Last Name
	First Name
	Title
	Home Address

	City, State, Zip
	Home Phone
	Home Phone	(include area code)
	Work Phone	Ext.
	Work Phone	(include area code)
	Fax Number
	S.S. Number
	E-mail Address

Accounts to Access:	Name	Account Number

AUTHORIZATION

I(we) authorize Community Bank-Wheaton/Glen Ellyn (the Bank), or its authorized agent, to transfer money to and/or from the accounts designated above. When available, transfers to and/or from loan accounts are additionally authorized. This authorization will extend to provide transfers to creditors should I (we) choose to use the Bill Payment service. I (we) acknowledge receipt of, and agree to abide by, the rules and regulations established for these services, which may be periodically amended (rules and regulations include Federal Regulations E, Privacy Policy and User Terms and Conditions as established by the Bank and any service provider contained by the Bank to provide these services). It is understood that Service Fees may be applicable and are to be deducted from the Bill Payment account listed above. Unsatisfactory handling of the accounts may result in revocation of service.

By submitting this application, I (we) authorize the Bank to verify all information contained herein. I (we) further authorize the Bank to obtain credit history from outside sources now and/or in the future, including, but not limited to credit bureaus and Chex Systems.

I (we) acknowledge that a temporary password will be issued to login to the system which I (we) will need to change. I (we) acknowledge that giving out the password compromises security measures that the Bank has put in place to protect my (our) account(s). In order to keep security at the highest level, I (we) will keep the login and password information private.

To apply, print this completed application and fax, mail or bring it to any of our locations.