Bill Payment/Mobile Deposit Access Form

"*" indicates required fields

Name*

First Last

Last Four Digits of Your Social Security Number*

Date of Birth*

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 Bank to establish you as a Bill Payment and/or Mobile Deposit Customer as designated above.

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