TITLE:

Grenada Co-operative Bank Limited

Mr. Mrs. OtherMs.

FIRST & MIDDLE NAME:

LAST NAME:

MOBILE # 1:

MOBILE NETWORK:

COUNTRY:

MOBILE # 2:

MOBILE NETWORK:

COUNTRY:

E-MAIL ADDRESS 1:

E-MAIL ADDRESS 2:

WORK PHONE #:

HOME PHONE # :

MAILING ADDRESS:

RESIDENTIAL ADDRESS:

Alert Delivery Method (C1) :

Subscribe for Marketing Alerts:

Enable Bill Payment by Text:

Text

Yes No

Customer Role:

Yes No

C1- Alerts( see below) C2 - Basic

Email

Application Form

Amount:

Account to Debit:

STANDING ORDER INFORMATION

Account Type: DDA

SAVBoth

EMPLOYER NAME:

JOB TITLE:

International Debit Card # :

BANK ACCOUNT NUMBERS

Please provide your IDC card number and or any of your Account Numbers

PRIMARMY CIF

ST.GEORGE'S GRENVILLESAUTEURS GRAND ANSE CARRIACOU

RETAIL BANKING UNIT

FOR BANK USE ONLY

PASSWORD

USER ID

ACCOUNT HOLDER SIGNATURE

Application reviewed and verified by:

FOR BANK USE ONLY

Application Approved by:

DATE

DATE

DATE

DATEApplication Inputted by:

TRANSFER INACCOUNTS VIEW ONLY

TRANSFER IN & OUT TWO TO SIGN

USER PERMISSIONS

RELATED CIF

ACCOUNTS TRANSFER INVIEW ONLY

TRANSFER IN & OUT TWO TO SIGN

USER PERMISSIONS

By signing below, I hereby certify that all the information provided are true, correct and complete and are madefor the purpose of: obtaining the Co-op Bank eBanking service; authorizing the Bank to obtain such informationas the Bank may require concerning the statements herein; agreeing that this application shall remain the Bank'sproperty; and acknowledging my responsibility to inform the Bank of any change in name(s), address, telephonenumber(s) and account(s) signing privileges within three (3) working days.

The Bank reserves the rights to collect fees and charges for the use of the Co-op Bank eBanking Service,including any service provided therein, and I hereby authorize the Bank to debit my Account for such fees andcharges.

I hereby acknowledge that I have read and understood the terms and conditions governing the Co-op BankeBanking service, a copy of which is annexed hereto and hereby incorporated by reference and I agree to bebound thereby.