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Online Banking Enrollment Form
Customer Information
  * denotes required field
First Name*: Middle Initial: Last Name*:
Driver License #: Social Security*:
Date of Birth*:
City*: Zip Code*:
Home Phone*: Work Phone:
Mobile Phone*:
Email Address*:
Mother's Maiden Name*:
Login ID

Please enter your desired Login ID. Each Login ID must be unique and contain 6 - 32 characters. It may consist of letters, numbers and/or symbols. Each customer's Login ID must be unique. If the Login ID you have requested is not available, First Bank Kansas will provide a similar but alternate Login ID for you.

Login ID*:
Account Access Information
Please provide the Account Number and Account Type 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
Signature & Disclosures
Signature*: Date*:
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