Enrollment Form

To sign up for Internet Banking, complete and print the application. Sign the form and send it to Page County State Bank, 120 E. Washington St., Clarinda IA  51632, fax (712-542-5300), or hand deliver to either Page County State Bank location. Once the form is returned to us, you will receive a letter containing your login ID, initial password and instructions for logging on.
Customer Information
First Name:
Last Name:
Address:
City:
State:  Zip:  Phone:
E-Mail:
Social Security Number:
Primary Checking Acct. #:
CHECK THE ACCOUNT ACCESS OPTIONS

Internet Banking

Internet Bill Pay

Access account balances, transfer money, and conduct common banking tasks online Access Bill Pay (you must enroll in Internet Banking
to access Bill Pay)
Account Information:  Please Note: You must be an authorized signer on each of these accounts.
Account Number: Access Type*: Account Description:  Account Type:
1)  
2)  
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6)  
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8)  
*Definitions for Access Type
  • Full Access - You will have the full access available on this account.
  • View & Deposit - You may view account information and transfer funds into this account.
  • View Only - You will be able to view balances and transactions.
  • Deposit Only - You will be able to transfer funds into this account from other accounts with Full Access. You will not be able to view balance or transaction information.
I/we certify that everything stated in this application and on any attachments is correct.  You may keep this enrollment form whether or not it is approved.  By typing and submitting this form, I authorize Page County State Bank to issue a temporary password on my behalf which I will be required to change to a private password the first time I log in to the system, I also agree to all provisions stipulated within the Internet Banking Access Agreement.

Applicant Signature:              Date: 

Joint Applicant Signature:     Date: