The First State Bank's Online Banking Enrollment Form.
Items with an * must be filled out.
Login Information
Please select Login-ID between 1-15 characters. It may contain all letters or a combination of letters and numbers and cannot contain spaces. Please select a Login-ID that you can remember as you will use this Login-ID once your account is activated.
Desired Login Name*:
When logging in for the first time, make sure to check box "I am a first time user".
Customer Information
Please provide at least one email address and one phone number to receive your secure access code for your Online Banking login. You will be required to set your password after entering your secure access code.
First Name*: Middle Initial: Last Name*:
Driver License #: Social Security #*:  
City*: State*: Zip Code*:
Home Phone*: Work Phone:  
Mobile Phone*:  
Email Address*: Bank Use Only:
Account Access Information
Please provide the Account Number, Account Type and Access Level for each account that you wish to access using Online Banking. All accounts must have the same ownership as the information provided in Customer Information above.
Account Number Account Type Access Level Access Level Description

Full Access: View account(s) and make all online transactions

View & Deposit: View account(s) and make online deposits, NO withdrawals

View Only: View account(s), NO online transactions

Deposit Only: Make online deposits, NO viewing or withdrawals

Signature & Disclosures:
Please Note: You must be an owner or authorized signer on each of these accounts.
I certify that everything I have stated in this application is correct. You may keep this application whether or not it is approved. I understand and acknowledge that if my situation changes I will be responsible for notifying you. Specifically individuals that have right or privileges granted by me that are changed or revoked. I understand that I may not revoke or change the rights of a joint owner of my account. If I have questions I will notify my local branch for clarification.
I Accept
*Signature: *Date:
  (Type your full name)   (Today's Date)