BANK VI NetTeller
Online Banking/Bill Pay
Enrollment Form



Instructions:  Print and complete this form, sign it, and bring it with picture ID to:

1900 South Ohio

Salina, Kansas 67401†††††


We will establish your BANK VI NetTeller service and contact you with instructions for sign-on.






Email Address:  (required)*     _____________________  Date: ______________________




Are you currently a BANK VI NetTeller Customer?  Yes____   No____







Name 1:  ________________________________†††



Social Security/ ID Number 1: ______________________ 




Date of Birth____________________


Drivers License Number or Government Approved ID (attach photocopy):____________________



Name 2:  _________________________________



Social Security/ ID Number 2: _______________________


Date of Birth _____________________

Driverís License Number or Government Approved ID (attach photocopy):____________________




Note:  P O Box holders must furnish a physical address as well as a mailing address!






Residential/Business Address:______________________________________ 




City: _______________________ State: _____________Zip Code: ___________________ 




Mailing Address (if different from above)_______________________________ 




City: _______________________ State: _____________Zip Code: _____________              




Identifying question for account:


Motherís Maiden Name ___________________          


City in which you were born: ___________________________




Home Phone #____________________†† Alternate Phone #___________________




Please access the following accounts:     




Account Number

††††††††††† Account Type














Bill Pay Enrollment



All Checking Accounts will be accessible for Bill Pay.



  Bill Pay    $4.95 per month with 10 free items; additional items are $.40


each.Charge the following account: __________________________







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 BANK VI 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 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 NetTeller Services Agreement and such other terms and conditions or amendments thereto, as may be established by BANK VI 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. BANK VI is not liable for late charges or other penalties associated with late receipt of payment by the payee. I authorize BANK VI 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:

BANK VI, 1900 South Ohio, P.O. Box 77, Salina, Kansas67402-0077






Signature:  __________________________________________


Date: _______________



Signature†† __________________________________________

























Member FDIC†††††††††† An Equal Housing Lender