Commercial Online Bill Pay Enrollment "*" 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 DigitsChecking Account Number (2) Last Four DigitsChecking Account Number (3) Last Four DigitsChecking Account Number (4) Last Four DigitsName of Business* Business Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business PhoneBusiness FaxBusiness Email APPLICANT’S INFORMATION:Applicant's Name* First Last Applicant's Email* Applicant's Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicant's Phone 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; Bill Pay Module, $10/month Bill Pay Additional Accounts, $5/month Bill Pay Items (first 20 items/month free), $0.65/each additional item 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. Terms of Consent* I have read and understand the Service Terms for Commercial Online Bill Pay.Entry of your name and date below will serve as your electronic signature.Name (Signature)* Date* MM slash DD slash YYYY