Business Online Banking Application

To apply for online banking, fill in the information below and press the Submit button.

By submitting this Application, I acknowledge that I am an authorized signer on all business accounts which will be designated on the Business Online Agreement. United Republic Bank will contact you to further set up access and provide you with the Business Online Agreement.

Business Information

Business Name Tax ID Number Business Phone Number Employee Phone Number

Business Type Sole Proprietor Corporation Partnership LLC Non-Profit Other

Business Type Street Address City State Zip Code Mailing address is different than street address. Mailing Address City State Zip Code

Signer Information

First Name Middle Initial Last Name Suffix Social Security Number Birth Date Business Phone Number E-mail Address

Will Signer be an Online User? Yes No

Certification

I certify that all information provided by me herein, including attachment(s) is true, correct and complete. I agree to provide any further information the Bank might require to process my application. United Republic Bank will contact you once your application is received to gather further information for Online set-up and send you the Business Online Agreement.

Applicant's Signature Date Type the numbers you see above:

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