Online Banking and Bill Payment Application Form

To sign up for Online Banking and Bill Payment, please complete this form electronically, print it, sign it, and bring it, fax it or send it to:
The Guernsey Bank, PO Box 1040, Worthington, OH 43085, Phone: (614) 854-0400, Fax: (614) 854-6989.

Please review the enrollment procedures at
The fields which are marked with an asterisk (*) are required fields.

First Name:* 
Last Name:* 

Street Address:* 

Zip Code:* 
Security Word:* 
Driver's License Number or State ID Number:* 
Issuing State of Driver's License or State ID:* 
List the Guernsey Bank Account numbers for each of the accounts you would like to have linked to Online Banking. (If there are not enough spaces provided, please inform one of the branch staff while setting up your account).
Account Number 1:  Account Number 2: 
Account Number 3:  Account Number 4: 
Account Number 5:  Account Number 6: 
Account Number 7:  Account Number 8: 
Account Number 9:  Account Number 10: 
If choosing to enroll in Bill Pay, please list the Guernsey Bank Checking Account number from which you would like your bills paid:
Account Number: 

By applying for and/or using the services indicated above, I agree to the terms of the Online Banking and Bill Payment Agreement and certify that I am a U.S citizen and at least 18 years of age. I also certify that all information I may furnish now or hereafter is true and complete; and I authorize and consent to: a) investigation and verification of my application and account information, b) the Bank sharing of such information with others including credit and check reporting agencies as well as any Bank Service Providers. The undersigned, jointly and severally, agree to be responsible for all charges, advances, and other fees and to abide by all of the terms governing the services and my accounts. Additional terms and conditions may be provided with The Guernsey Bank Online Banking and Bill Payment Service and other services. I understand that this application will remain the property of the Bank. By selecting The Guernsey Bank Online Banking and Bill Payment Service, I understand and acknowledge that I have authorized The Guernsey Bank to provide The Guernsey Bank Online Banking and Bill Payment Service as indicated previously. Use of The Guernsey Bank Online Banking and Bill Payment Service or other online banking products shall be deemed to be my written authorization to charge, debit, or credit my account(s) for the amount and type of transaction(s) and/or fees indicated at the time of use. The Guernsey Bank is hereby authorized to rely and act upon telephone and other electronic instructions received from me or my authorized user in accordance with Bank guidelines. Read our Consumer Privacy Statement.


I wish to enroll in (Please select one):

Online Banking AND Bill Payment
Online Banking Only
Bill Payment Only (You must have an existing Online Banking Account to enroll in Bill Payment only.)


Signature:______________________________    Date:________________    Form: IB-APP_8-25-05