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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 sent to the appropriate bank representative via our SECURE Messaging. We will process your request for an online account during normal business hours.

*First Name:			MI:
*Last Name:
Business Name:(DBA)
*Mailing Address:
Street Address: (if different)
*City/State/Zip:
*Primary Phone:
Alternate Phone:
Cell Phone:
*Email Address:
*Re-enter Email Address:
*Primary Accountholder Last four of SSN

Account Number(s):

1		6
2		7
3		8
4		9
5		10

*REQUIRED Entries

By clicking the 'I Agree' button below, I certify that the information provided is true and correct. I authorize the Vintage Bank Kansas 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 Vintage Bank Kansas' Online Access Agreement and Disclosure Statement and I agree to the terms and conditions.

Upon verification of information submitted on this form, a Vintage Bank Kansas Personal Banker will contact you with your initial login credentials.