Platte Valley Bank  
NetBANKING/Bill Pay Personal Application

NEW CUSTOMER sign up for NetBANKING!
Complete the ENTIRE Personal Application below. If you also want Bill Pay, review and identify the Bill Pay Plan Option #
you want and also identify the checking account number to be used for Bill Pay (see below).

If you are a current NetBANKING customer and want Bill Pay, complete only the application items in "BLUE" in addition to your *Netteller ID#.
Then, review and identify the Bill Pay Plan Option # you want, and identify the checking account # to be used for Bill Pay (below).

Note: You need to use the "Personal" application for a small business account, d/b/a, if your business tax ID number is your social security number.
Each joint account owner must complete their own application.

First Name:

Middle Initial:

Last Name:

Social Security Number:

Mother's Maiden Name:

Driver's License Number:

Driver's License State:

Address:

City:

State:

Zip Code:

*Netteller ID Number:
for current users only

Day Phone:

( ) -

Evening Phone:

( ) -

E-mail Address:

Re-type E-mail Address:

Below, list the account numbers and title of accounts, to which you are an owner, and would like to have NetBANKING access.

*Use up to 20 characters (do not use punctuation, but spaces can be used) to identify you accounts. These names can be changed on
NetBANKING once you are signed-on.

Account Number(s) for NetBANKING

Title of Account*

BILL PAY APPLICATION

Yes... I want Bill Pay.

BILL PAY PLANS
(identify Plan you want below)
Consumer Accounts-

Plan Option 02
$2.95 monthly charge with 4 free payments
and forty cent charge per item over 4;

or

02

Plan Option 03
$4.95 monthly charge with 20 free payments
and forty cent charge per item over 20.

or

03

Ambassador Club/
Professional & Executive Accounts-

Plan Option 04
$2.95 monthly charge with 20 free payments and
forty cent charge per item over 20.

04

Identify the checking account # you want tied to Bill Pay below.

I am a Current Customer:

I am not a customer and will need to open at least one eligible account with Platte Valley Bank for NetBANKING, which could include either a checking account, savings account, money market account, certificate of deposit, IRA, installment loan and/or line of credit.

To have Bill Pay I will need to have one active checking account.

NE: Scottsbluff (308) 632-7004 WY: Torrington (307) 532-2111 WY: Wheatland (307) 322-9215
Copyright © 2007 Platte Valley Bank. All rights reserved. Members FDIC. Equal Housing Lenders.