Annandale State Bank Online Banking Enrollment Form
 
 
*Required Fields
 
Login Information
Please enter your desired User Name. Each User Name must be unique. Your User Name can contain up to 20 characters consisting of letters, numbers and symbols. You may choose any of these 'special' characters`~!@#$%^&*()_+-={}|[]:?;?<>?,./\ If the User Name you have requested is not available, Annandale State Bank will provide a similar but alternate User Name for you.
User Name*:
 
Member Information
Please provide at least one email address and one phone number to receive your secure access code for your Online Banking login. You will be required to set your password after entering your secure access code.
First Name*: M. I.: Last Name*:
Social Security #*:  
Address*:  
Address:
City*: State*: Zip Code*:
Home Phone*: Work Phone:  
Mobile Phone:  
Email Address*: Bank Use Only:
 
Account Access Information
Please provide the Account Number(s) that you wish to access through Online Banking. All accounts must have the same ownership as the information provided in the Customer Information above.
*Account Number(s):
 
Signature & Disclosures:
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*Signature: *Date:
  (Type your full name)   (Today’s Date)