Electronic Access Enrollment Form

* Denotes a required field. All required fields must be completed in order to process your enrollment request.

Name*
First Last
Last Four Digits of Your Social Security Number*
Date of Birth*
MM
DD
YYYY
Address*
Street Address City State ZIP Code
Cell Phone*
Home Phone*
Email Address*
Bill Pay
- Please enroll me in Bill Pay
I acknowledge that Bill Pay assesses a separate Overdraft Fee of $20 for each item in addition to the bank's Overdraft Fee.
Mobile Deposit
- Please enroll me in Mobile Deposit
Requested Per Check Limit:
Requested Daily Deposit Limit:
Acknowledgement*
- By checking the box you are acknowledging that you agree to the following:
The terms and conditions of the “Online Banking Agreement,” “Mobile Services Agreement,” “Terms and Conditions of The Bill Payment Service,” and/or “Electronic Disclosure and Consent,” and you request Longview State Bank to establish you as a Bill Payment and/or Mobile Deposit Customer as designated above.
Phone
This field is for validation purposes and should be left unchanged.