Enrollment Form

To sign up for Internet Banking, complete and print the application. Sign the form and return it in person to any full service DeMotte State Bank location. At that time, you will receive your log-in ID and first time password.

Customer Information

Primary Applicant Information

First Name:
Last Name:
Address:
City:
State:	Zip: Phone:
E-Mail:

Mothers Maiden Name:
Place of Birth:
Fathers Middle Initial:
Social Security Number:
Primary Checking Acct. #:

Account Options

	Internet Banking			Electronic Bill Payment
	Access account balances, transfer money, and conduct common banking tasks online			Pay bills on-line. Pay any individual or company. $4.95 per month

Account Information

Account Number:	*Access Type:**	Account Description:	Account Type:
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4)
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7)
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*Definitions for Access Type

Full Access - You will have the full access available on this account.
View & Deposit - You may view account information and transfer funds into this account.
View Only - You will be able to view balances and transactions.
Deposit Only - You will be able to transfer funds into this account from other accounts with Full Access. You will not be able to view balance or transaction information.

Please Note: You must be a holder with ownership rights to access each of these accounts.

I certify that everything I have stated in this application and on any attachments is correct. You may keep this application whether or not it is approved. By typing and submitting this form, I authorize you to check my credit and employment history, to have a consumer credit report prepared on me for the purpose of evaluating this application for credit, and to answer questions others may ask you about my credit record with you. I understand that I must update this credit information at your request and if my financial condition changes.

Applicant Signature: Date: