Billpay Application

Bill Payment Application

Please print this application and take it to one of our five convenient locations or fax to (740) 922-6376.

Name:_____________________________________          SSN/TIN:_____________________

Spouse:____________________________________         SSN/TIN:_____________________

E-Mail:________________  Home Phone:__________________

E-Mail:________________ Home Phone:___________________

Address:______________________________________________________

Drivers License Number:                          ______________________________

Spouse Drivers License Number:               ______________________________

Checking Account# 041209420 Description ______________________________

I authorize The First National Bank of Dennison to withdrawal funds from the checking account indicated on this application when I have generated payment transactions by personal computer through the FNB Home Banking Bill Pay Service. I understand that I am in full control of my account.

If at any time I decide to discontinue service, I will provide written notification to The First National Bank of Dennison. My use of FNB Home Banking Bill Pay signifies that I have read and accepted all of the terms and conditions of FNB Home Banking Bill Pay.

I understand that payments may take up to 10 days if by check and up to 4 days if by electronic payment, to reach the vendor. The First National Bank of Dennison is not liable for any service fees or late charges levied against me. I also understand that I am responsible for any loss or penalty that I may incur due to a lack of sufficient funds or other conditions that may prevent the withdrawal of funds from my account.

I (we) authorize The First National Bank of Dennison to make inquiries or any credit investigation in reference to my (our) character or credit habits. The Ohio law against discrimination requires that all creditors make credit equally available to all credit-worthy customers, and that credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio Civil Rights Commission administers compliance with this law.

Fees:  Free with Bonus Checking, Gold and Gold 50 / Plus Checking - Free Checking account is $ 5.95 monthly (first 10 payments included)$32.00 Insufficient Funds  $ .40 per payment after 10 $ 5.00 Canceled Check Copy  $20.00 Stop Payments



X_____________________________ x_____________________________
Signature (1)                             Spouse (2)
  
Date__________________________
 

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FOR FINANCIAL INSTITUTION USE ONLY 

Internet Banking ID # ________________________ 

Plan: ________________
 
Input:________________  Checked by: ____________

Date:________________