Online Banking Enrollment Form

****For Personal Online Banking Enrollments ONLY****

Customer Information
* Indicates required fields
First Name * : Middle Initial: Last Name*:
Social Security # * :  
Date of Birth * :
Address * :
City * : State * : Zip Code * :
Home Phone * :
Work Phone:
Mobile Phone:
Email Address * :
User Name:
Please enter your desired User Name. Each User Name must be unique. Your User Name must contain a minimum of 8 characters with a maximum 15 characters consisting of upper case letters and numbers. You may choose any of these 'special characters'~!@#$%^&*(). If the User Name you have requested is not available, Hyden Citizens Bank will provide a similar but alternate User Name for you. Our Recommendation is to use your email address.
User Name * :
Account Access Information:
Please provide the Account Number(s) for each account you wish to access through Online Banking. All accounts must have the same ownership as the information provided in the customer information provided 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.

I understand that this online banking will be set up (pursuant to my/our instructions) with the functions, features and/or additional provisions indicated above and that my use of this service will be subject to make any investigation of my credit either directly or through any agency. I understand that Hyden Citizens Bank will retain this application and any credit information, even if I am not approved for this online banking. I agree not to use this service in any illegal activity. I hereby authorize Hyden Citizens Bank to add the accounts listed above to the Online Banking functions for inquiries, transfers and bill paying on my accounts. 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 Hyden Citizens Bank.
* Signature: * Date:
Note: Once your application is approved and processed, within 72 hours excluding non-working days you will receive an email with your confirmed User Name and information to access your Online Banking account. You will be required to set your password after entering your secure access code. At least one email address and one phone number are required on your application to receive your secure access code for your Online Banking login.