Citizens Tri-County Bank
E-statements enrollment

Checking Account Number/s _________________________________________________

Savings Account Number/s __________________________________________________

Name 1: __________________________________________________________________

Name 2: __________________________________________________________________

Address: _________________________________________________________________
_________________________________________________________________

City: ______________________________ State: _____________ Zip: _______

Phone: ____________________________ Fax: _______________________

E-mail Address: ____________________________________________________________

PC Operating System:
(circle one)Win 3.1, Win 95, Win 98, Win 2000,
Macintosh, or Other____________________

By signing below you represent that you have read, understood, and agreed to the conditions of receiving your statement via email and that you have caused this enrollment form to be execute and warrant that you or your signatories, whose signatures appear below, have been and are as of the date of this form, duly authorized by all necessary action in accordance with their governing instruments, if applicable, to execute this enrollment form. I also understand I may receive additional disclosures from Citizens Tri-County Bank via e-mail and that I am responsible for notifying the Bank of any changes in my e-mail address.

AGREED TO AND ACCEPTED:

By: ________________________________________________

By: ________________________________________________

Printed Name(s): _____________________________________

Date: _______________________________________________

Please designate your Personal Identification Number (PIN). The PIN must be a minimum of eight alphanumeric characters and a maximum of ten. Please print in uppercase* letters.

*The PIN will not be case sensitive

___________________________________

Member FDIC Equal Housing Lender


*Please print out this application and send it to us ASAP!