Online Banking Enrollment

<form method="post" action="https://secure2.profitstarscms.com/2450/app_process.asp"> <input value="https://secure2.profitstarscms.com/2450/mirror/thankyou.htm" type="hidden" name="redirecturl" target="_parent" /><input value="aking@hcbwv.com, kvernon@hcbwv.com, tbutcher@hcbwv.com" type="hidden" name="bankemail" /><input value="customer@hcbwv.com" type="hidden" name="fromvalue" /><input value="forms/" type="hidden" name="folder" /><input value="2450/" type="hidden" name="bankpath" /><input value="OnlineEnrollment" type="hidden" name="app_name" /> <table class="formcontent" border="0" cellspacing="4" cellpadding="4" width="700" align="center"> <tbody> <tr> <td colspan="4" align="center"> * = Required Fields </td> </tr> <tr> <td class="formheading" bgcolor="#1f4b78" colspan="4" align="center"> Name </td> </tr> <tr> <td width="25%" align="center"> Title (optional)<br /> <input id="Title" size="6" type="text" name="Title" /><br /> &#160; </td> <td width="25%" align="center"> <p> First Name *<br /> <span id="sprytextfield1"><input id="FirstName" type="text" name="FirstName" /><br /> <span class="textfieldRequiredMsg">A value is required</span></span> </p> </td> <td width="25%" align="center"> Middle Initial<br /> <input id="MiddleInitial" size="2" type="text" name="MiddleInitial" /><br /> &#160; </td> <td width="25%" align="center"> Last Name: *<br /> <span id="sprytextfield2"><input id="LastName" type="text" name="LastName" /><br /> <span class="textfieldRequiredMsg">A value is required.</span></span> </td> </tr> <tr> <td class="formheading" valign="top" colspan="4" align="center"> &#160; </td> </tr> <tr> <td class="formheading" bgcolor="#1f4b78" valign="top" colspan="4" align="center"> Information </td> </tr> <tr> <td align="left"> Street Address * </td> <td align="left"> <span id="sprytextfield3"><input id="StreetAddress" type="text" name="StreetAddress" /><br /> <span class="textfieldRequiredMsg">A value is required.</span></span> </td> <td align="left"> &#160; </td> <td align="left"> &#160; </td> </tr> <tr> <td align="left"> Address 2 <span class="formcontentsmall">(PO Box #...Appt #)</span> </td> <td align="left"> <input id="Address2" type="text" name="Address2" /> </td> <td align="left"> &#160; </td> <td align="left"> &#160; </td> </tr> <tr> <td align="left"> City * </td> <td align="left"> <span id="sprytextfield4"><input id="City" type="text" name="City" /><br /> <span class="textfieldRequiredMsg">A value is required.</span></span> </td> <td align="left"> &#160; </td> <td align="left"> &#160; </td> </tr> <tr> <td align="left"> State * </td> <td align="left"> <span id="spryselect1"><select id="State" name="State"> <option selected="true" value="Please Select"> Please Select </option> <option value="IN"> IN </option> <option value="AK"> AK </option> <option value="AL"> AL </option> <option value="AR"> AR </option> <option value="AZ"> AZ </option> <option value="CA"> CA </option> <option value="CO"> CO </option> <option value="CT"> CT </option> <option value="DC"> DC </option> <option value="DE"> DE </option> <option value="FL"> FL </option> <option value="GA"> GA </option> <option value="HI"> HI </option> <option value="IA"> IA </option> <option value="ID"> ID </option> <option value="IL"> IL </option> <option value="KS"> KS </option> <option value="KY"> KY </option> <option value="LA"> LA </option> <option value="MA"> MA </option> <option value="MD"> MD </option> <option value="ME"> ME </option> <option value="MI"> MI </option> <option value="MN"> MN </option> <option value="MO"> MO </option> <option value="MS"> MS </option> <option value="MT"> MT </option> <option value="NC"> NC </option> <option value="ND"> ND </option> <option value="NE"> NE </option> <option value="NH"> NH </option> <option value="NJ"> NJ </option> <option value="NM"> NM </option> <option value="NV"> NV </option> <option value="NY"> NY </option> <option value="OH"> OH </option> <option value="OK"> OK </option> <option value="OR"> OR </option> <option value="PA"> PA </option> <option value="RI"> RI </option> <option value="SC"> SC </option> <option value="SD"> SD </option> <option value="TN"> TN </option> <option value="TX"> TX </option> <option value="UT"> UT </option> <option value="VA"> VA </option> <option value="VT"> VT </option> <option value="WA"> WA </option> <option value="WI"> WI </option> <option value="WV"> WV </option> <option value="WY"> WY </option> </select><br /> <span class="selectInvalidMsg">Please make a selection.</span><span class="selectRequiredMsg">Please make a selection.</span></span> </td> <td align="left"> Zip Code * </td> <td align="left"> <span id="sprytextfield5"><input id="ZipCode" type="text" name="ZipCode" /><br /> <span class="textfieldRequiredMsg">A value is required.</span></span> </td> </tr> <tr> <td colspan="4" align="center"> <hr size="1" noshade="true" /> </td> </tr> <tr> <td align="left"> Date of Birth * </td> <td colspan="2" align="left"> <span id="sprytextfield6"><input id="DateOfBirth" type="text" name="DateOfBirth" /> (mm/dd/yyyy)<br /> <span class="textfieldRequiredMsg">A value is required.</span><span class="textfieldInvalidFormatMsg">Invalid format.</span></span> </td> <td align="left"> &#160; </td> </tr> <tr> <td align="left"> Social Security Number * </td> <td colspan="2" align="left"> <span id="sprytextfield7"><input id="SSN" type="text" name="SSN" /> ( xxx-xx-xxxx)<br /> <span class="textfieldRequiredMsg">A value is required.</span><span class="textfieldInvalidFormatMsg">Invalid format.</span></span> </td> <td align="left"> &#160; </td> </tr> <tr> <td align="left"> Daytime Phone * </td> <td align="left"> <span id="sprytextfield8"><input id="DaytimePhone" type="text" name="DaytimePhone" /><br /> <span class="textfieldRequiredMsg">A value is required.</span></span> </td> <td align="left"> &#160; </td> <td align="left"> &#160; </td> </tr> <tr> <td align="left"> Account Number * </td> <td align="left"> <span id="sprytextfield9"><input id="AccountNumber" type="text" name="AccountNumber" /><br /> <span class="textfieldRequiredMsg">A value is required.</span></span> </td> <td align="left"> &#160; </td> <td align="left"> &#160; </td> </tr> <tr> <td align="left"> E-mail Address * </td> <td align="left"> <span id="sprytextfield10"><input id="Email" type="text" name="Email" /><br /> <span class="textfieldRequiredMsg">A value is required.</span><span class="textfieldInvalidFormatMsg">Invalid format.</span></span> </td> <td align="left"> &#160; </td> <td align="left"> &#160; </td> </tr> <tr> <td align="left"> Desired User ID * </td> <td colspan="3" align="left"> <span id="sprytextfield11"><input id="DesiredUserID" type="text" name="DesiredUserID" /> 8 - 12 characters in length (alpha &amp; numeric)<br /> <span class="textfieldRequiredMsg">A value is required.</span><span class="textfieldMinCharsMsg">Minimum number of characters not met.</span><span class="textfieldMaxCharsMsg">Exceeded maximum number of characters.</span></span> </td> </tr> <tr> <td align="left"> Second Choice User ID * </td> <td colspan="3" align="left"> <span id="sprytextfield12"><input id="SecondChoiceUserID" type="text" name="SecondChoiceUserID" /> 8 - 12 characters in length (alpha &amp; numeric)<br /> <span class="textfieldRequiredMsg">A value is required.</span><span class="textfieldMinCharsMsg">Minimum number of characters not met.</span><span class="textfieldMaxCharsMsg">Exceeded maximum number of characters.</span></span> </td> </tr> <tr> <td align="left"> City of Birth * </td> <td align="left"> <span id="sprytextfield13"><input id="CityOfBirth" type="text" name="CityOfBirth" /><br /> <span class="textfieldRequiredMsg">A value is required.</span></span> </td> <td align="left"> &#160; </td> <td align="left"> &#160; </td> </tr> <tr> <td align="left"> Mother&#39;s Maiden Name * </td> <td align="left"> <span id="sprytextfield14"><input id="MothersMaidenName" type="text" name="MothersMaidenName" /><br /> <span class="textfieldRequiredMsg">A value is required.</span></span> </td> <td align="left"> &#160; </td> <td align="left"> &#160; </td> </tr> <tr> <td align="left"> Bill Pay * </td> <td align="left"> <span id="spryradio1"><label><input id="RadioGroup1_0" value="Yes" type="radio" name="BillPay" /> Yes</label>&#160;&#160;&#160;&#160; <label><input id="RadioGroup1_1" value="No" type="radio" name="BillPay" /> No</label><br /> <span class="radioRequiredMsg">Please make a selection.</span></span> </td> <td align="left"> &#160; </td> <td align="left"> &#160; </td> </tr> <tr> <td colspan="4" align="center"> &#160; </td> </tr> <tr> <td class="formheading" bgcolor="#1f4b78" colspan="4" align="center"> Please Certify Your Information </td> </tr> <tr> <td colspan="4" align="left"> <span id="sprycheckbox1"><input id="VerificationAuthorization" value="Yes" type="checkbox" name="VerificationAuthorization" /> As a condition for processing my request, I authorize verification of my identification and/or other information.<br /> <span class="checkboxRequiredMsg">You must authorize to continue.</span></span> </td> </tr> <tr> <td colspan="4" align="center"> <a target="_blank" href="files/ONLINE_BANKING_AGREEMENT_AND_DISCLOSURE.pdf" > </a> <p> View OLB Agreement </p> </td> </tr> <tr> <td colspan="4" align="center"> <input id="button" value="Submit Form" type="submit" name="button" /> </td> </tr> </tbody> </table> </form>