Internet Banking Enrollment Form

Internet Banking Enrollment Form
	P. O. Box 1718 Houma, LA 70361-1718 Phone: (985) 851-3434 Fax: (985) 879-3095
New Change
Please complete and print the following information to register for Internet Banking services. The application must be signed in accordance with your signature card agreement on file with the bank. You may mail or fax the completed application to us. For your protection, we will not accept a completed application via the Internet or e-mail. Upon receipt, we will mail you a unique "User ID" and password instructions. Your "User ID" and password will allow you to access our Internet Banking services. Upon your first log-on to the system, you should change your password to one of your choosing.
Ownership Information
Personal	Business

Name:

Street Address:

Street Address2:

City, State: Zip

Email Address:

List all account numbers that you wish to access via Internet Banking. The Bill Payment feature is only available for Checking Accounts.

Function Code A = Add B = Change D = Delete	Account Number	Bill Pay
Example: A	Example: 123456

I have read and agree to the terms and conditions set forth in the "Online Banking Agreement and Disclosure Statement". I certify that I am authorized to sign on the accounts listed above. I understand that I will receive my "User ID" and password instructions in the mail and will keep them confidential to protect my accounts.
_____________________________________	_____________________________________
Authorized Signer	Authorized Signer
______________________________________	_____________________________________
Date	Date

Internet Banking Fees

	Consumer Accounts	Commercial Accounts
Internet Banking	Free!!	Free!!
Bill Payment Service	TWO MONTHS FREE!! $4.95 per month up to 20 bills. 40 cents per bill in excess of 20.	ONE MONTH FREE!! $6.95 per month up to 20 bills. 60 cents per bill in excess of 20.
Corporate Cash Management Service	Not Available	Coming Soon!