Bill Payment/Mobile Deposit Access Form

Please note: you must be enrolled in Online Banking before signing up for Bill Payment or Mobile Deposit services.

"*" indicates required fields

Name*

First Last

Last Four Digits of Your Social Security Number*

Date of Birth*

YYYY

Address*

Street Address City State ZIP Code

Cell Phone*

Home Phone*

Email Address*

Bill Pay

Please enroll me in Bill Pay

Mobile Deposit

Please enroll me in Mobile Deposit

Requested Per Check Limit:

Requested Daily Deposit Limit:

Acknowledgement*

By checking the box you are acknowledging that you agree to the following:

The terms and conditions of the “Online Banking Agreement,” “Mobile Services Agreement,” “Terms and Conditions of The Bill Payment Service,” and/or “Electronic Disclosure and Consent,” and you request Longview Community Bank to establish you as a Bill Payment and/or Mobile Deposit Customer as designated above.

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