Bank@Home Application

Primary Account Holder Applicant Information

Social Security or Tax Identification Number††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††

First Name††††††††††††††††††††††††††††††††††††††††††††† Middle Initial†††††††††††††† Last Name†††††††††††††††††††††††††††††††††††††††††

Mailing Address††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††

City, State, Zip†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††

Home Phone ††††††††††††††††††††††††††††††††††††††††††††††††††† ††Work Phone ††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††

Email Address††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††

Date of Birth †††††††††††††††††††††††††††††††††††††††† ††Mother's Maiden Name††††††††††††††††††††††††††††††††††††††††††††††††


Account Information (accounts to be accessed with BANK@HOME)

Check here to include all owned accounts in relationship ______

Acct Number/Type:††††††††††††††††††† †††††††††††††† Acct Number/Type:††† ††††††††††† †††††††††††††††††††††††

Acct Number/Type:††††††††††††††††††† †††††††††††††† Acct Number/Type:††† ††††††††††† †††††††††††††††††††††††

Acct Number/Type:††††††††††††††††††† †††††††††††††† Acct Number/Type:††† ††††††††††† †††††††††††††††††††††††

Acct Number/Type:††††††††††††††††††† †††††††††††††† Acct Number/Type:††† ††††††††††† †††††††††††††††††††††††



Services (place check mark by selected services) †††††††††††††††††††††††††††††††††††††††††

Service†††††††††††††† ††††††††††† Monthly Fee

_____ Internet Banking††††††††††† Free

_____ Bill Payment †††††††††††††††† $5.95 for 15 Free Bills and $.35 for Each Additional Bill (per account) First six months fee waived




You must be an owner/co-owner for all accounts in which you are requesting access.


Use of your Bank@Home ID and PIN is the agreed security procedure to access and use Bank@Home services including online transfers. In order to prevent unauthorized access to your accounts and to prevent unauthorized use of these online services, you agree, by using Bank@Home, to keep confidential, and to not give or make available your ID or PIN, or other means to access your Online account to any person not authorized to access your accounts. If you permit any other person(s) or entity to use your online account by giving them your ID, PIN, or other means to access your account, you are responsible for any transactions and activities they authorize from your account(s).


If selected, I understand that I have the ability to pay my bills and make other payments through the Bill Payment service. I understand that with this service I can initiate and authorize payments from my primary checking account to my designated payees. I have read and understand the guidelines as set forth in the Bank@Home Disclosure. I authorize bank to use any means necessary including obtaining credit report to verify eligibility for Bill Payment services.


Deliver the completed application in person to any Citizenís Bank location.


Primary Account Holder Signature:††††††††††††††††††††††††††††††††††††††††††††††††††† ________________