Please print out this form, complete, sign, date and either
Mail to: PO Box 350, Honesdale PA 18431,
FAX to 570-251-9519 or Deliver to any HNB Office
Last Name:_______________________ First:_______________ MI:___
Email Address:_____________________________________________
SSN:____________________________ Birthdate:________________
I/we are authorized signors on the accounts listed below and would like to have access to them via HNB's Internet Banking Service. HNB will provide a special Account Identifier in place of the actual account numbers which I/we can change to suit my/our needs. HNB recommends that we not use the actual account numbers as identifiers.
Account Number___________________ Account Type: __________
Account Number___________________ Account Type: __________
Account Number___________________ Account Type: __________
Account Number___________________ Account Type: __________
Account Number___________________ Account Type: __________
Account Number___________________ Account Type: __________
HNB MONEYLINE Bill Payment Option
HNB BILL PAYER Plan: Monthly Charge Paid by HNB, Unlimited number of transactions. Free Bill Payer services will be suspended after 90 days of inactivity.
Account to charge for Bill Payments #____________________ (DDA Only)
Account Verification (used if Moneyline password is lost) _____________________________________________________________
Please Read Before Signing
By signing below I/we request to be enrolled in the The Honesdale National Bank's Internet Banking Service. I/we certify that the information provided is true and correct and authorize The Honesdale National Bank to verify any information included in this application and allow Internet access only to the accounts listed above on which I am an authorized signer. The use of HNB's Internet Banking Service shall be governed by the terms and conditions of the INTERNET BANKING AGREEMENT AND DISCLOSURE STATEMENT, available on the Disclosure Page of this Website and such other terms, conditions or amendments as may be established by The Honesdale National Bank and communicated in writing to me. I understand that account security is controlled by the Log-In ID and Personal Identification Number (PIN). My PIN must be changed the first time that I log onto HNB's Internet Banking Service. I will protect my Log-In ID and PIN and hold The Honesdale National Bank harmless from any unauthorized use. Any information downloaded by me becomes my personal property and responsibility.
Signature:________________________________ Date:____________
Signature:________________________________ Date:____________
Bank Use Only
Input Date:_________ Input By:_________
Log-In ID#:__________ Acct/Signature Verified:___________
Verified By:__________ Confirm Mailed:__________