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^{CURRENT ADDRESS                                      CITY                                   STATE             ZIP                                   E-MAIL ADDRESS}

 IN THE SPACES BELOW LIST ALL ACCOUNT NUMBERS FOR WHICH YOU ARE A SIGNER AND WISH TO ACCESS VIA THE NETTELLER ON-LINE INTERNET BANK SYSTEM.  FOR SECURITY REASONS, WE DO NOT SEND OR REQUEST YOUR ACCOUNT NUMBERS OVER THE INTERNET.  FOR EACH ACCOUNT NUMBER LISTED SELECT A SHORT DESCRIPTIVE NAME (20 CHARACTERS OR LESS INCLUDING SPACES  – SPECIAL CHARACTERS ARE NOT ALLOWED). SOME EXAMPLES MIGHT BE CHECKING, SAVINGS, CAR LOAN, HOME EQUITY LOAN, etc.  DO NOT USE THE SAME NAME FOR TWO DIFFERENT ACCOUNTS.  IF YOU HAVE TWO OR MORE CHECKING OR SAVINGS ACCOUNTS, QUALIFY THEM IN SOME WAY SUCH AS JOINT CHECKING, SPECIAL CHECKING (OR SAVINGS) SO YOU WILL BE READILY ABLE TO IDENTIFY THE ACCOUNT BY THE NAME ONLY.  REMEMBER SINCE THE ACCOUNT NUMBERS ARE NOT SENT OVER THE INTERNET THEY WILL NOT APPEAR ON YOUR INTERNET SCREEN.                                          

PLEASE READ CAREFULLY BEFORE SIGNING

 NOTE: ALL APPLICANTS WILL HAVE ACCESS TO ALL ACCOUNTS LISTED ABOVE. IF THIS IS NOT DESIRED, THE APPLICANTS SHOULD PREPARE SEPARATE APPLICATIONS LISTING THE ACCOUNTS TO BE ACCESSED BY THAT INDIVIDUAL.

 I certify that the information provided is true and correct.  I authorize Grand Valley National Bank/Heber Valley National Bank to verify any information included on this application and allow access to all the accounts listed above on which I am a signer.  The use of NETTELLER is governed by the printed terms and conditions of the NETTELLER INTERNET BANKING  AGREEMENT and such other terms and conditions or amendments thereto, as may be established by Grand Valley National Bank/Heber Valley National Bank and communicated to me in writing. I/we agree to be bound by the terms of the NETTELLER INTERNET BANKING AGREEMENT  as it exists today and as amended in the future. To the extent permitted by law, I/we agree to hold Grand Valley National Bank/Heber Valley National Bank harmless from damage caused by my/our own negligence.

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^{SIGNATURE                                             DATE                                            SIGNATURE                                               DATE}

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FOR BANK USE:  

Initials ___________________ Date ______________NETTELLER