Business Online Bill Pay Enrollment - First Mid Bank & Trust

Please complete the following form to request CheckFree Business Bill Pay services. You must have a business checking account at First Mid Bank & Trust to sign up for Business Online Bill Pay services.

"*" indicates required fields

INSTRUCTIONS:

Please verify all information is correct and complete;
Please provide all requested information, including valid US address and phone number;
Submission of completed form constitutes a request for Online Bill Pay Services.

BUSINESS INFORMATION:

Tax ID*

Checking Account Number (1)*

Last Four Digits

Checking Account Number (2)

Last Four Digits

Checking Account Number (3)

Last Four Digits

Checking Account Number (4)

Last Four Digits

Name of Business*

Business Address

Street Address City State ZIP Code

Business Phone

Business Fax

Business Email

APPLICANT'S INFORMATION:

SSN*

Last Four Digits

Date of Birth*

Applicant's Name*

First Last

Applicant's Email*

Applicant's Address

Street Address City State ZIP Code

Applicant's Phone

Driver's License Number and State

SERVICE TERMS:

The person(s) submitting this application is/are acting with full authority for the applying entity. This application for online services has been duly authorized by the Board of Directors, members or general partners, as applicable, of the applying entity. Should this application for online services be accepted, the applying entity:

Agrees to defend, indemnify and hold the service harmless from any misuse of or unauthorized access to the online services performed on behalf of or in the name of the applying entity;
Authorizes the business' financial institution to debit the account indicated on this application, for payments requested through the service and for the appropriate monthly bill payment service fee;
Understands that all service fees will be automatically debited monthly from the designated bank account until further notification to cancel the service is provided; and
Agrees that use of the service signifies acceptance of all the terms and conditions of the service.

Entry of your name and date below will serve as your electronic signature.

Name (Signature)*

Date*