THE BANK HAZLEHURST Online Banking Application

Please check the box indicating the type of Online Banking service requested:

Online Banking OR

Online Banking with Online Bill Payment

     MEMBER FDIC

NOTE: Must be a BANK HAZLEHURST customer to apply. Please complete the application online. Print, sign and return to the address below.

Account Owner/Signer Information

Please provide information for each account owner or signer on the accounts that will be accessed through Online Banking. Ownership on all accounts must be the same and match the individual(s) listed below.

Name – Primary Account Owner/Signer               

Name – Joint Account Owner/Signer

Name – Business Account(if applicable)

Name – Business Account(if applicable)

E-Mail

E-Mail

Account Information

Please provide the Account Type and the Account Number for each account that will be accessed using Online Banking. Please note all accounts(s) must have the same ownership as the individuals(s) indicated above.

1.  Checking Savings  CD Loan

3. Checking Savings CD Loan

Account #:

Account #:

2.   Checking Savings CD Loan

4. Checking Savings CD Loan

Account #:

Account #:

Please indicate which checking or savings account should be charged for all Online Banking Service Fees.

Please indicate which checking account should be charged for the Online Bill Payment transactions.

Account #:

Account #:

ONLINE BANKING TERMS AND CONDITIONS AGREEMENT

I (We, if joint account holder) have reviewed the “Online Banking Terms and Conditions Agreement” for THE BANK HAZLEHURST Online Banking Service and Optional Bill Payment Service and accept such Online Banking Terms and Conditions Agreement. By using the online financial services provided by THE BANK HAZLEHURST, I/We agree to abide by the terms and conditions of this agreement. I/We hereby authorize THE BANK HAZLEHURST to charge the primary account indicated above each month for the appropriate fee amount as outlined in the Online Banking Terms and Conditions Agreement

______________________________________

______________________________________

Signature-Primary Account Owner/Signer

Date

  Signature - Joint Account Owner/Signer                    Date

Return Application to THE BANK HAZLEHURST or Mail To:

Bank of Hazlehurst
P.O. Box 628

Hazlehurst, GA 31539

MEMBER FDIC

Upon receipt of completed application, an Online Banking Welcome Letter will be mailed to the applicant(s) to the address on file with THE BANK OF HAZLEHURST. This letter will include your first time logon instructions and temporary account Access ID and Password.

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