Personal Online Banking Enrollment Form

1 Start 2 Complete

Customer Information

First Name: *

Middle Initial: *

Last Name: *

Drivers License #:

Address: *

City: *

State: *

Zip Code: *

Home Phone: *

Cell Phone:

Email Address: *

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

View & Deposit: View account(s) and make online deposits, NO withdrawals.

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

Deposit Only: Make online deposits, NO viewing or withdrawals.

Account Number

Account Type

Access Level

Account Number

Account Type

Access Level

Copy of Account Number

Copy of Account Type

Copy of Access Level

Copy of Copy of Account Number

Copy of Copy of Account Type

Copy of Copy of Access Level

Copy of Copy of Copy of Account Number

Copy of Copy of Copy of Account Type

Copy of Copy of Copy of Access Level

Copy of Copy of Copy of Copy of Account Number

Copy of Copy of Copy of Copy of Account Type

Copy of Copy of Copy of Copy of Access Level

Copy of Copy of Copy of Copy of Copy of Account Number

Copy of Copy of Copy of Copy of Copy of Account Type

Copy of Copy of Copy of Copy of Copy of Access Level

Copy of Copy of Copy of Copy of Copy of Copy of Account Number

Copy of Copy of Copy of Copy of Copy of Copy of Account Type

Copy of Copy of Copy of Copy of Copy of Copy of Access Level

Secure Access for Password Setup

To access our online banking experience, please provide at least one phone # and email address to receive your banking secure access code for Online Banking login. You will set your password after entering your secure access code.

Email 1: *

Phone 1: *

Email 2

Phone 2:

Email 3:

Phone 3:

Signature & Disclosures

By clicking submit below, I certify that everything I have stated in this enrollment is correct. I authorize Wells River Savings Bank to issue a temporary password on my behalf which I will be required to change to a private password the first time I log into the system.

I accept the terms above

Signature: *

Date: *

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Personal Online Banking Enrollment Form