I request access to the accounts listed below via Citizens Online.
| Checking | Savings | Loans | Other |
I agree that the use of Citizens Online will be subject to the terms and conditions contained in the Deposit Account Agreement, Customer Access Agreement, and the Regulation E Disclosure that have been provided to me.
By signing below, I request the bank to issue a user Login ID and Personal Identification Number (PIN).
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Customer Signature and Date
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Customer Email Address