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:



Zip Code:

Home Phone #:

Cell Phone #:

Work Phone #


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