Mercantile Bank – Internet Banking Enrollment Form
 
Customer Information

Name(s) on Account(s):
Address:
                
City:              State:      Zip: 
SSN/TIN:                
 E-mail Address:    
Home Phone:          
Business Phone:   
 
Please list all account numbers you wish to access and the type of access (NOTE: If you have a joint account, both enrollees must be authorized per account for Internet access otherwise a separate authorization form may be necessary.):
 Account Number                   Type                                Access**
      
      
      
      
      
      
      
      
      
      
Access**    FULL means the user has complete access to the account.
                     VIEW ONLY means the user may only view the account history.
                     DEPOSIT ONLY means the user may only deposit to the account.
                     VIEW AND DEPOSIT means the user may view history and deposit to the account.
Login ID: A) You may select your Internet Login ID. The Login ID must be at least five (5) characters (alpha/numeric) but must begin with an alpha character. Login ID's will be case sensitive and, unless specified, the Login ID will be entered in all lower case letters.
Login ID
B) You will be provided an initial Internet Banking System password to login the first time. You will be required to change that password the first time you log on. Passwords are case sensitive, must be between eight (8) and ten (10) alpha/numeric characters and contain at least one special character (! @ # $ % ^ * > ? , etc.). Your initial Internet Banking System password will be emailed to you as an encrypted message or will be mailed to you through the US Postal Service system which may take approximately 1-3 business days.

Requested Internet Banking Services:

that will allow you to access account balances, transfer funds, and conduct common banking tasks online. This service is not subject to a fee, however, other disclosed service charges may apply.
that will provide an electronic version of your bank account statement and images. This service is not subject to a fee, however, other disclosed service charges may apply.
    Estatement Password
that will allow access to pay bills online to individuals or companies. This service is subject to a fee. (The current sercive fee for Bill Payment is $6.95, which may be adjusted at the discretion of the bank, for UNLIMITED transactions.)
If you wish to enroll for Bill Payment, please indicate the checking account you wish to have charged for the monthly service fee:
  Account Number
is designed to allow access to business accounts to transact banking tasks to include Bill Payment and other automated functions. This service is subject to a fee. (The current service fee for e-Cash Management is $19.95 per month, which may be adjusted at the discretion of the bank, for UNLIMITED transactions.)
If you wish to enroll for e-Cash Management, please indicate the checking account you wish to have charged for the monthly service fee:
  Account Number

Authorized Account Holder Signature(s) Required for Enrollment:

I, the undersigned, hereby consent to allow the following named individual(s) to access my account(s) listed above under the login ID which is listed above. Such individual(s) shall have all rights and privileges associated with such login ID, which may include the right to transfer account balances and pay bills.

(Printed Name)         
(Signature)              
(Date)                        
(Printed Name)       
(Signature)              
(Date)                        
(Printed Name)        
(Signature)              
(Date)                        
(Printed Name)       
(Signature)              
(Date)                        

Upon Completion, please review and make a note of your requested login ID and/or eStatement password.
To submit your enrollment form, please print and sign it. You may drop it off at your most convenient Mercantile Bank location, or you may mail or fax it to
:

Mercantile Bank
Attn: Internet Enrollment
P.O. Box 3455
Quincy, Illinois 62305-3455
217-223-1907 (Fax) 

 

For Internal Use Only

CSR:                        ______________________  Date:    _____________
JHA CIF Number: __ __ __ __ __ __ __ __
JHA Short Name: __ __ __ __ __ __ __ __ __ __ __ __ __
Data Services
Login ID:                ____________________________
Input by:                 ______________________  Date:    _____________
Verified by:            ______________________  Date:    _____________