Enrollment Form

Complete the information fields below and hit the submit button at the bottom. You will receive an email from our Internet Banking Department within 24-48 hours providing your log-in ID and temporary password for new Online Banking enrollments.

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 Estatements Electronic Bill Payment
Access account balances, transfer money, and conduct common banking tasks online The paperless solution to quickly and securely view your account statements online. Pay bills on-line. Pay any individual or company. Monthly fees may apply.
Account Information
Account Number: Access Type*: Account Description:  Account Type:
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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.

By signing below, I authorize DeMotte State Bank to issue a Login ID and temporary password on my behalf which I will be required to change upon initial login. I also acknowledge that I have read and agree to the terms and conditions of the E-Sign Disclosure. I also understand the importance of maintaining the confidentiality and security of my Login ID and password and agree that the Bank may perform any transactions initiated under my Login ID and password without my signature. I understand that if I share my Login ID and password with any person, that I am granting them access to my accounts, permission to transact business on my accounts and I assume all the risk of their access.

Applicant Signature:            Date: