Online Banking Enrollment Form
*** For Personal Online Banking Enrollments Only **
Business Customers: Please contact your local branch for enrollment.
Customer Information
  * denotes required field
First Name*: Middle Initial: Last Name*:
Social Security*:
City*: State: Zip Code*:
Province: Country:
Home Phone*: Mobile Phone:
Work Phone: Ext:
Email Address*:
Driver License #*: Date of Birth*:  
User Name

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, Aliant Bank will provide a similar but alternate User Name for you.

User Name*:
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  Signature*: Date*:
  (Type Your Full Name Here) (Today's Date)