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To sign up for Mid Penn Bank On-Line, read the terms of the On-Line Access Agreement and EFT Disclosure, then fill in the information below and print the enrollment form and mail it to the address at the right. In a few days, you will receive a letter containing a temporary password.  Use this password, in conjunction with the Log-in ID that you choose below, to log into On-Line Banking.  The first time you log-in, you will be forced to change your password.

* I have read and agree to the terms of the On-Line Access Agreement and EFT Disclosure. (*This box must be checked in order to process your enrollment form. Additional forms may be sent to you for completion if you have a joint account, limited access accounts, etc.)

(A) APPLICANT INFORMATION (Please Print)
First Name  
Middle Initial
  
Last Name  
Social Security Number  
Date of Birth  
Address  
City  
State
Zip Code
  
Home Phone  
E-Mail  
Choose a log-in ID   (5-8 characters) This will be your permanent Log-in ID. Your Log-in ID cannot start with a number, nor can it contain any symbols.
Bank Code* (*Enter only if you have been given a bank code for promotional use.)
(B) ACCOUNT INFORMATION
    Please list only accounts for which you are an owner or joint owner.
 
Account Number
Account Type
Choose your own Account Description
(i.e.: "John's Account," "House Account," etc.)
User Rights
1.
 
 
2.
 
 
3.
 
 
4.
 
 
5.
 
 
6.
 
 
To complete section (B) above, please use the following "account types" and "user rights" information:

Account Types:
Checking (includes Checking, Money Market, etc.)
Savings (includes Statement Savings, IRA's & Club Accounts)
Loan
Time Deposit (Includes CD's)		 User Rights:
Full Rights: May View, Deposit, and Transfer Funds
Deposit Only: May only deposit into account
View Only: May only view account balance and activity
Deposit and View: May view account activity/balance and deposit into account.

(C) JOINT ACCOUNT OWNERSHIP AUTHORIZATION
This portion MUST be completed if any of the above accounts have joint account ownership.
By signing below, I have read the On-Line Banking Agreement and Electronic Fund Transfer Act Disclosure including the fee schedule and agree to all terms and conditions. I hereby authorize Mid Penn Bank to allow access to and to honor any transaction(s) made to or from all accounts jointly held with the above named applicant, using the applicant's Log-In ID and password.
Print co-owner's name
Signature
Date
 
_________________________
 
_________________________
 
_________________________
 
_________________________
 
_________________________
 
_________________________
(D) APPLICANT'S AUTHORIZATION
1. I hereby authorize on-line access to all accounts that I have listed on this enrollment form. I have completed all the necessary account access information.
 Yes
 No
  • Full Access includes the ability to view account balances, account history and to deposit and transfer funds.
  • For accounts held jointly, each co-owner(s) must also sign section (c), the Joint Account Ownership Authorization, of this enrollment form authorizing you to access jointly held accounts. This form authorizes access for the applicant only. Co-owners(s) must complete a separate enrollment form for access.
  • Limited access acounts may require additional access agreements be completed and will be added to your On-Line Banking access only after such agreements have been completed and signed, where applicable, by the appropriate accountholder(s).
2. I would like to apply for the On-Line Bill Payer Option
 Yes
 No
Please link my line of credit, account number to my
        bill pay service.
By signing below, I have read the On-Line Banking Agreement and Electronic Fund Transfer Act Disclosure including the fee schedule and agree to all terms and conditions. I authorize Mid Penn Bank to honor any transaction(s) made using my Login ID and password. I understand that access to Mid Penn Bank On-Line will not be effective until all information has been verified and a temporary password has been communicated to me via the postal mail. I hereby authorize Mid Penn Bank to issue me a temporary password that I must change the first time I log onto Mid Penn Bank On-Line.
Applicant's Signature
Date
__________________________________________________
 
Print, and mail completed form to
Mid Penn Bank, Attn: On-Line Office Manager,
349 Union Street, Millersburg PA 17061

If you cannot print this application, please call our On-Line Office Manager at
(717) 692-7146, or e-mail us at mpbank@epix.net, and ask for an On-Line Enrollment Form to be mailed to you.

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