Net XPress Online Banking/Bill Pay Enrollment Form

Instructions:    Complete this form, sign it and bring or mail it to Citizens State Bank & Trust Co., PO Box 128, 203 N Douglas, Ellsworth, KS 67439. We will establish your Net XPress Service and contact you with instructions for sign-on.

  Email Address:  (required)*          Date: 
   Are you currently a Net XPress Customer?      Yes     No

  Name 1:      Social Security/ ID Number 1: 
  Name 2:      Social Security/ ID Number 2: 
Note:  P O Box holders must furnish a physical address as well as a mailing address!
  Residential Address: 
City:      State:     Zip Code: 
  Mailing Address (if different from above):       
  City:      State:     Zip Code:                     Answer
 Identifying question for account:                     
  Birth Date 1:   Birth Date 2:    Cell Number:   
  Home Phone #:    Work Phone #:    Other Phone #:  
  Driver's License # 1:      Issuing State:    Expiration Date:  
  Driver's License # 2:      Issuing State:    Expiration Date:  
  OR other approved government issued photo ID#:  

Please access the following accounts:      NOTE:  Loans, Christmas Club, and Certificate of Deposits will not have transfer capabilities.
  Account Number

     Account Type

Net XPress will use your Account Nickname (such as Joes Checking, Home Loan, etc.) to replace your account number for better security.  Nicknames cannot have special characters, such as commas, and you can change them anytime.  Also referred to as "Pseudo Names".

Bill Pay Enrollment

                                  Please indicate below if you would also like the Bill Pay option included with your Net XPress Account.  All Checking Accounts will be accessible for Bill Pay.

  Bill Pay                    FREE with signed Enrollment Form

  Please Read Before Signing - I certify that the information provided is true and correct and that I am the owner of these accounts or the duly authorized representative of the owner and authorized to act for the owner. I authorize Citizens State Bank & Trust Co. to verify any information by credit check, prior banking activity, employment history, and/or other information should it deem necessary to confirm my identify and evaluate by account status in compliance with the USA PATRIOT Act of 2001 and related laws and regulations and to allow access to all accounts listed above. I have received and agree to the terms and conditions of the Net XPress Services Agreement and such other terms and conditions or amendments thereto, as may be established by Citizens State Bank & Trust Co. and communicated to me. I agree not to allow anyone to gain access to the Services using my Password or to let anyone know my Password. I accept all responsibility for all transactions initiated under my login ID and Password, up to the limits allowed by applicable law.
  Bill Payment - I understand that I will be responsible for determining the payee of such payments, scheduled pay date, account to be used for bill payments, and the availability of funds in my account. I understand that any payment made without sufficient funds in my account will be returned and my account will be charged an overdraft fee. I also understand that bill payment may take the form of a check and may take up to ten (10) days to reach the payee. Citizens State Bank & Trust Co. is not liable for late charges or other penalties associated with late receipt of payment by the payee. I authorize Citizens State Bank & Trust Co. to debit my account for all bill payment fees. If at any time I desire to discontinue bill pay, I may do so upon written notification to Citizens State Bank & Trust Co., Net XPress, PO Box 128, Ellsworth, KS 67439


Signature:  ______________________________________________________   Date:  _______________





Net XPress Online Banking/Bill Pay Application  - Page 2

Please access the following accounts:   NOTE:  Loans, Christmas Club, and Certificate of Deposits will not have transfer capabilities.
  Account Number

     Account Type

You may choose additional accounts to be added to your Net XPress Account listings.  You must be a joint owner or authorized on the account to gain access to the information.
For Internal Use Date received:  _____________________ Net XPress ID #:  __________________
  Date Net XPress set up:___________________________________ By:_______________________________  
  Date Bill Pay set up: ______________________________________ By:_______________________________  
  Date Verified:  __________________________________________ By:_______________________________  
ID and Password given to applicant: __________________________ By:_______________________________