E-Statement Enrollment Form

First Name

Middle Name

Last Name

*X Required
Business Name

*X Required
Email

*X Required
Home/Business Phone Number

*X Required
Cell Phone Number

*X Required
List of FCB accounts for which you would like to receive E-Disclosures:
x
Account Number (1)

*X Required
- Account Type (1)
VALUE+-
*XRequired
E-Disclosure(s) Requested (1) E-Disclosure(s) Requested (1)
- e-Statements & e-Notices
- e-Statements only
VALUE+-
*XRequired
Account Number (2)

*X Required
- Account Type (2)
VALUE+-
*XRequired
E-Disclosure(s) Requested (2) E-Disclosure(s) Requested (2)
- e-Statements & e-Notices
- e-Statements only
VALUE+-
*XRequired
Account Number (3)

*X Required
- Account Type (3)
VALUE+-
*XRequired
E-Disclosure(s) Requested (3) E-Disclosure(s) Requested (3)
- e-Statements & e-Notices
- e-Statements only
VALUE+-
*XRequired
Acceptance of E-Disclosures Addendum and Consent to Receive E-Disclosures. When you click on the Accept button below, you will have electronically signed this Addendum to your electronic banking agreement. Your electronic signature indicates your consent to be bound by the terms of this Addendum and to receive E-Disclosures; and your acknowledgment that you have compliant equipment which will enable you to view, save, and print PDF files. If you select the Ask Me Later button below, you will be asked again in 30 days. If you select the Decline button, you will not be enrolled in the E-disclosure Service and you will not receive E-Disclosures.
x
Please Note: E-Disclosure Notification will only be emailed to one email address per account. Please Note: E-Disclosure Notification will only be emailed to one email address per account.
- By checking this box, you acknowledge that you have read and agree to the Terms and Conditions defined in our E-Disclosures Addendum.
VALUE+-
*XRequired

VIEW OUR E-DISCLOSURES ADDENDUM:
E-Disclosures Addendum