Personal Online Banking Enrollment Form
Customer Information
  * denotes required field
First Name*: Middle Initial: Last Name*:
Drivers License #*: Social Security #*:
Date of Birth*:  
City*:   Zip Code*:
Home Phone*: Work Phone:  
Mobile Phone:  
Email Address*:  
User Name

Please enter your desired User Name. Your User Name can contain up to 15 characters consisting of letters, numbers and symbols. May contain any of these 'special' characters:`~!@#$%^&*()_+-={}|[]:?;?<>?,./\. Each customer’s User Name must be unique. If the User Name you have requested is not available, Planters Bank will provide a similar but alternate User Name for you. Please note that this request will fail to process if there is a space at the end of the user name.

User Name*
Account Access Information
Please provide the Account Number, Account Type and Access Level 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 Access Level Access Level Description

Full Access: View account(s) and make all online transactions including transfers.

View Only: View account(s), NO online transactions.

How did you hear about our Online Banking?
Please let us know how you heard about us.
Signature & Disclosures
  Signature*: Date*: