Please print and mail or fax to: (E-mail will not be accepted for security reasons)

Peoples National Bank of Mora
PO Box 88
Mora, MN 55051
Fax: 320-679-3109

INTERNET BANKING APPLICATION

Existing customers of Peoples National Bank of Mora may print, mail or fax this application. If you are not currently a customer of Peoples National Bank of Mora, please visit one of our offices nearest you.

One customer per application:

Customer Name: _________________________________________________________

Social Security Number: ____________________ Date of Birth: _____________

E-mail address: ___________________________________________________________

Security Question: ________________________________________________________

Security Answer: _________________________________________________________

Home Telephone: _____________________ Work Telephone: ____________________

Access ID ____________________
*ID and passwords are case sensitive – print clearly
(This will be a 6 digit log-on code that remains constant. This can be alpha, numeric, or a combination. We will issue a temporary password.)

Please list all account numbers on which you are a signer and would like to access. (All accounts must have the same Owner and Tax Identification Number.)

_______________________________ ______________________________

_______________________________ ______________________________

_______________________________ ______________________________

Account Owner’s Signature:

____________________________________

Signature

**PLEASE SIGN ME UP FOR E-STATEMENTS TODAY!     ______YES    
(No additional charge for E-Statements)

===============================================================

For Bank Use Only

Security/CIS Information Verified ___________ Date ___________

Port # ______________ Name Line #_________

Password and Disclosure Mailed _____________________ Date __________________