Bank of Wausau Net Teller Application
Print, fill out, sign, and mail to: Bank of Wausau,
P.O. Box 1406, Wausau, WI 54402-1406
LAST NAME:_____________________________ FIRST
NAME:__________________
MIDDLE INITIAL:___
SSN:___________________
HOME PHONE:__________________ WORK
PHONE:__________________
E-MAIL:_________________________________
CURRENT
ADDRESS:______________________________________________
CITY:_____________________________________STATE:_________
ZIP:___________________
List below all accounts that you
are a signer on and would like to be able to have access to. Also
list the description you would like to use for each account you have
selected. We will not pass any of your account numbers over the
Internet. Examples of some account descriptions you might use are:
checking, savings, consumer loan, home loan, commercial loan, etc.
There is a limit of 20 characters (including blanks) in the
description. Special characters are not allowed; Use only letters,
numbers, and spaces. Do not use the same description for different
accounts.
ACCOUNT DESCRIPTIONS (20 characters max)
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ACCOUNT #:____________________________
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ACCOUNT #:____________________________
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ACCOUNT #:____________________________
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ACCOUNT
#:____________________________
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ACCOUNT #:____________________________
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ACCOUNT #:____________________________
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ACCOUNT #:____________________________
FOR BANK USE:
INITIALS:_____________ DATE:_____________________
ID#:______________________________________________
PLEASE READ BEFORE SIGNING
AUTHORIZATION & AGREEMENT:
Upon application approval, all of my eligible accounts I hold with
the Bank of Wausau, will be included in my NetTeller services.
I hereby authorize you, Bank of Wausau, to establish NetTeller to
enable me to perform the transactions described in the service
agreement. I authorize you to process transactions for me as
requested from time to time, and authorize you to post them to my
accounts. I authorize you to make any automatic recurring
payments upon my direction. I further authorize you to debit
my checking account for the appropriate monthly fee for the services
requested above. I understand that my account will be debited
monthly until I cancel the service. I agree that my first use
of NetTeller services will signify my acceptance of the other terms
of the service agreement you will supply, along with instructions
for using the services.
The Undersigned agrees to the same terms stated on
the above,
Signature:________________________________________________
Date:____________________________________
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