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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*:
User Name

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

User Name*:
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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