BILL EXPRESS APPLICATION

Primary Account Name:

SS# Primary:

Joint:

Address:

City/State/Zip:

Phone: Day:

Eve.:

E-mail address

Date of Birth: Primary:

Joint:

Mother's Maiden Name
(For security purposes)

I AUTHORIZE Avidia Bank to post payment transactions generated through the Internet from the Bill Express Service to the account indicated on the attached voided check. I understand that I am in full control of my account. If at any time I decide to discontinue service, I will provide written notification to Avidia Bank. My use of the Bill Express Service signifies I have read and accepted all the terms and conditions of the Bill Express Service.

I UNDERSTAND that payments may take up to ten business days to reach the vendor and that they will be sent either electronically or by check. Avidia Bank is not liable for any service fees or late charges levied against me. I also understand that I am responsible for any loss or penalty that I may incur due to lack of sufficient funds or other conditions that may prevent the withdrawal of funds from my account.

We must have your signature or signatures below:

Signature: Primary:

Date:

Signature: Joint

Date: