Enrollment Form

	To sign up for Online Banking, fill in the information below, print and sign the completed form, then either fax or mail it to the Bank. In a few days, you will receive a letter containing a Login ID and a temporary password.  Use this password, with your Login ID to log in to Online Banking.  The first time you log in, you will be forced to change your password. Online Banking with account access only is a free service. The Bill Payer service with unlimited transactions is also a free service.

	Customer Information:

	First Name:

	Last Name:

	Address:

	City:

	Phone:

		State:
	E-Mail:

	Zip:

	Social Security Number:

	Primary Checking Acct. Number:

	* * List additional account numbers on the bottom of this form.

□ Internet Access Only □ Internet Access with Unlimited Bill Payer Signature:___________________________________________________

2732 Midwestern Pkwy  Wichita Falls, Texas 76308 Fax: (940) 397-2414
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