Customer Name 1_____________________________________________________ Customer Name 2_______________________________________________________

Mailing Address______________________________________________________ Mailing Address________________________________________________________

City, State, ZIP_______________________________________________________ City, State, ZIP_________________________________________________________

E-mail Address_______________________________________________________

Phone Number________________________(H)_________________________(W) Phone Number_________________________(H)_________________________(W)

Accounts to be included for Internet Banking access:

List Accounts and Identify Account Owner	Name 1	Name 2	Joint*
Account#
Account#
Account#
Account#
Account#
Account#
Account#
Account#

*Note: Any Joint Accounts will require all Account Holders Signatures on Internet Banking Agreeement

Continued on reverse side

• Upon opening deposit accounts at Nicollet County Bank you would have received a copy of Reg E. Check here if you would like to receive another copy.
• Upon opening deposit accounts at Nicollet County Bank you would have received a copy of Reg DD. Check here if you would like to receive another copy.
• Please check here if interested in receiving information regarding the Nicollet County Bank NetTeller Bill Pay Program.

By Signing Below:

1.      Customer(s) request to be enrolled in NetTeller Banking at Nicollet County Bank. I authorize Nicollet County Bank to verify any information included in this agreement and allow access only to those accounts that Customer(s) may be an authorized signer. The use and access to Nicollet County Bank NetTeller Internet Banking shall be governed by the terms and conditions of the Nicollet County Bank NetTeller Internet Banking Agreement and Disclosure statement.

2.      Customer(s) acknowledges receipt of the Federal Electronic Transfer Act Disclosure (Reg E).

3.      Customer(s) acknowledges receipt of Reg DD which regulates to transfers from Savings or Money Market Savings to six per month when initiated by telephone, electronic or other pre-authorized means.

Customer 1 Signature_________________________________________________ Customer 2 Signature_________________________________________________

Bank Use Only:

Date____________________      Initials____________________

Disclosure Requests Reg E Reg DD

NetTeller Disclosure Sent______________________

NetTeller ID ________________________________