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APPLICANT INFORMATION
First Name  
Middle Initial:
 
Last Name  
Social Security #:
E-Mail:
Log in ID:  

(A) PLEASE ADD THE FOLLOWING ACCOUNTS
Account Number Account Type Account Description: (example: John's account) User Rights
1.
2.
3.
Check this box if you want your Constant Credit linked to your checking account on-line. Be sure to list your Constant Credit account number above.
To complete section (A) 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.

(B) 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 Login ID and Password.
Co-Owner's Name: Signature: _________________________________ Date:
Co-Owner's Name: Signature: _________________________________ Date:
Co-Owner's Name: Signature: _________________________________ Date:

(C) PLEASE DELETE THE FOLLOWING ACCOUNTS
Account Number
Account Type *
Account Description: (example: John's account)
1.
2.
3.

(D) REVOCATION OF THIRD PARTY ACCESS AUTHORIZATION

Please complete the following information below if the owner of any accounts listed in section (c) is not the applicant making the request to remove the account.
Account Owner's Name: Signature: __________________________ Date:
Account Owner's Name: Signature: __________________________ Date:
Account Owner's Name: Signature: __________________________ Date:

(E) APPLICANT'S SIGNATURE

Account Owner's Name:
Signature: _________________________________
Date:


E-mail Request


Print, sign 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) 692-4000, or e-mail us at mpbank@epix.net, and ask for an On-Line Enrollment Form to be mailed to you.