Home Banking Enrollment Form

582 S. Round Barn Road. P.O. Box 817
Richmond, IN 47375
Phone: (765) 962-2561  •  Fax: (765) 966-3989




Member Information

Member Account Number:

First Name:

Middle Name/Initial:

Last Name:


Last 4 Digits Of Social Security #:

Birthdate (MM/DD/YYYY):

Email Address:


Street Address:

City:

State:

Zip Code:


Home Phone #:

Cell Phone #:

Work Phone #

Ext:


Create A 4 Digit Pin Number To Use On Your Intiial Login:


Submit Form

By submitting this request, I acknowledge that I have read and agree to the terms of the Home Banking Disclosure