First State Bank And Trust Company Internet Banking
Enrollment Form

To sign up for Internet Banking:

1) Complete the application;
2) Print a copy of the completed application using your browser's print button;
3) Submit it online to the bank by clicking the submit button;
4) Complete the application process by signing the printed form and bringing it to the bank.

If for some reason you cannot print the form, come to the bank, and we will print it for you.

You must come to the bank and see a New Accounts Representative who will process your application and assign you a user id and temporary password. You may choose a user id yourself, or we will assign one for you. If you choose a user id, it must be at least five characters long and may contain letters and/or numbers. An alternate choice for user id may be required if the one selected is already taken.

User Id:
Customer Information:
First Name: Last Name: MI:
City: State:  Zip:
Phone: E-Mail:
Social Security Number:
Primary Checking Account Number:
You must still list this number below with the proper account access definition. FULL access is required for the Bill Payment service. Any account without a proper definition listed will be set up as VIEW ONLY.

Requested Services:
Internet Banking (No Charge) Bill Payment
Access account balances, transfer money and conduct common banking tasks.

Personal Users - $5.00/month with 15 bill payments and $0.50/payment over 15.
Special Offer! $5.00 monthly fee will be reimbursed if at least one bill payment is made per month.

Account Information:
Example - checking 111-222-333 Full

Definitions for Access:
  • Full Access - You will have the full access available on this account (transfer to and from account).
  • View & Deposit - You may view account information and transfer funds to the account.
  • View Only - You will be able to view balances and transactions.

Please Note: You must be an authorized signer on each of these accounts. Accounts cannot be opened without the appropriate signature.

I also authorize First State Bank & Trust Co. to add any new accounts that I may open to my Internet Banking service.

Applicant's Signature: Date: