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Thank you for your interest in United Security Bank On-Line Banking. We appreciate your business and pledge to continue to provide the highest quality products and services to accommodate our customers.

Please complete the form below, and bring by our office location at 350 E. Broad Street to complete the sign-up for On-Line Banking.

Personal Information

     First Name:            ______________________________________

     Last Name:            ______________________________________

     Address Line 1:      ______________________________________

     Address Line 2:      ______________________________________

     City:                       ______________________________________

     State:                     ______________________________________

     Zip Code:              ______________________________________

     Social Security Number/ Tax ID:      _________________________

     Home Phone:         ______________________________________

     Work Phone:         ______________________________________

     Email Address:       ______________________________________

I certify that everything I have stated in this application is correct.

           _________________________________________________Signature

           _________________________________________________Date