Prosperity Internet Banking Services Application
This is a "print" application. Please print, complete, and forward to your local Banking Center.

Reviewed by:___________________________________________________

Input by:       ___________________________________________________

I am applying for: (check one) Prosperity Internet Banking only Prosperity Internet Banking with Bill Pay	Internet Banking Temporary User ID#
Personal Information (for Internet Banking set-up) Customer Name Address City State ZIP Code SS# E-mail address	Account Number (1) Account Number (2) Account Number (3) Account Number (4)
Please read the Internet Banking Services Agreement & Electronic Funds Disclosure
I have read the above referenced disclosures and agree to the terms and conditions. By signing below, I hereby accept the terms and conditions of the Agreement. I authorize Prosperity Bank to set up all accounts opened by me on Prosperity Internet Banking Services. I further authorize you to charge my account for any transactions processed through the use of Internet Banking, including the amount of any recurring payment or transfer that I make. I agree to comply with all of the above referenced disclosures.
Applicant Signature	Date
For Bill Pay Set-Up, please complete the following section.
Primary Account Number to Debit for Payments & Fees Home Phone Number Social Security Number Mother's Maiden Name (for account verification) Work Phone Number