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Sign Up for Internet Banking

Please provide us with the information requested below.   After you fill out and submit this form, it will be emailed to the appropriate bank representative via SECURE email.  We will call you to confirm your request for an on-line account during normal business hours, often the same day.

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.
What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

*First Name:  MI:
*Last Name: 
*Address Line 1:  
  Address Line 2:  
*City: *State: *Zip:
*Home Phone:
*Work Phone:
*Date of Birth:
*Social Security Number:
*Account 1:
  Account 2:
  Account 3:
*E-Statements(Yes or No):

By entering the confirmation codes below, I certify that the information provided is true and correct. I authorize First State Bank Valliant to verify the information on this enrollment form and allow access to all accounts listed above of which I am an owner. I further certify that I have read the Online Banking Agreement and the Electronic Disclosure, Electronic Signature and Electronic Statements Agreement and I agree to the terms and conditions thereof.
*Confirmation Code: Online Banking


(To complete your Signup for Internet banking you must click on the Online Banking Agreement link below to receive confirmation code.)
*Confirmation Code: E Disclosure



(To complete your Signup for Internet banking you must click on the E Disclosure/E Signature & E Statement Agreement link below to receive confirmation code.)


Online Banking Agreement
Electronic Disclosure, Signature and Statements Agreement

You will need Adobe Reader in order to view the Paperless Statements Service Agreement. Adobe Reader is free software used for viewing and printing electronic forms. To download, click here or go to and follow the online instructions.

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