Independent Bank's Online Banking Enrollment Form
  *Required Fields/font>  
  Customer 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*: Middle Initial: Last Name*:
Business Name:
Business CSA Name: Title:
City*: State*: Zip Code*:
Social Security/EIN:* Drivers License #:* Date of Birth:*
Home Phone*: Work Phone: Mobile Phone:
Email Address*:
  Secure Access Information  
A unique secure access code is required to register your computer and when you have forgotten your password. Secure Access Codes can be delivered by e-mail, voice by phone (or cell), and/or text by cell phone. Please provide the phone number and/or e-mail address that your secure access code should be delivered to.

Delivery Method: E-Mail Address or Phone Number:
Voice   Text   E-Mail
Voice   Text   E-Mail
Voice   Text   E-Mail
Voice   Text   E-Mail

Access to the following account(s):

Account Type: Account Number(s):
Checking   Savings   CD   Loan
Checking   Savings   CD   Loan
Checking   Savings   CD   Loan
Checking   Savings   CD   Loan
  • To initiate credit or debit entries to your checking, savings or loan account at another institution, please contact your local Independent Bank branch.
  Signature & Disclosures:  
This document is being secured with SSL encryption provided by your browser. Your information will be encrypted when using this form while in transit between your browser and Independent Bank.
*Signature: *Date:
  (Type your full name)   (Today's Date)