The First State Bank Columbus, TX

Electronic Statement Application

Sign up for Electronic Statements

1. Read the Frequently asked Questions for eStatements.
2. Read the Electronic Statements terms & Conditions.
3. Complete the eStatement Application below (one for each account).
4. Submit the Application.

**IMPORTANT

Before you submit the eStatement Application, you must read the Electronic Statement Terms & Conditions. By choosing to submit the eStatement Application, you are agreeing to the terms, conditions, and fees set out in the Electronic Statement Agreement.

Account Name: _______________________________________________

Address: ____________________________________________________

City: _______________________________________________________

State: ____________________________   Zip: _____________________

Home Phone #: ______________________________________________

Work Phone #: ______________________________________________

Cell Phone #: ________________________________________________

Email Address (Primary): ______________________________________

Email Address (Secondary): ____________________________________

Account Number/Numbers: _____________________________________

I have received, read and agree to the terms, conditions and fees set out in The First State Bank’s Electronic Statement Terms & Conditions. I understand my rights and obligations as a consumer of the eStatement service. I also understand the rights and the obligations of The First State Bank as the provider of these services.

Signed: ______________________________________________________

Printed Name: ________________________________________________