e -Statement Agreement and Registration Form

Use this form to add, remove, or change e-Statement services on your bank account. By completing this registration form, you elect to receive your bank statement electronically via Web Banking. The Bank will send an email to the email address on file as notification of your statement delivery.


* indicates a required field


Form Purpose:

Add e-statements to my account(s):
**Please note--All accounts combined with the above account will be included in your e-statement.

Add e-statements to my LOAN account(s):

Remove e-statements from my account(s):

Change E-Mail address information below:


*Account Number:
*First Name:
MI:
*Last Name:
*Social Security Number:
*Street Address (no P.O. boxes):
*City: ,
*State:
*Zip: -
*Daytime Phone: Ext:
*Night Phone:
*E-mail:

DISCLOSURE

ADDING THIS SERVICE AUTHORIZES THE BANK TO DISCONTINUE THE DELIVERY OF PAPER STATEMENT VIA U.S. POSTAL SERVICE FOR THIS ACCOUNT UNTIL WRITTEN CANCELLATION IS RECEIVED.

By checking the box below, I:


*I agree that I have read and understand the above terms:


Chemung Canal Trust Company Copyright 2001. All Rights Reserved.

Member FDIC
Equal Housing Lender