*Required Fields
Login Information
Desired Login ID*:
  • Must be at least 4 characters
  • Cannot be more than 20 characters
  • May contain any of these special characters: `~!@#$%^&*()_+-={}|[]:”;’<>?,./\
Client Information
Please provide your contact information below, including your phone number to receive your secure access code to log in to your account.
First Name*: Middle Initial: Last Name*:
Social Security #*:    
Address*:  
Address:
City*:   Zip Code*:
Home Phone*: Work Phone:  
Mobile Phone:  
Email Address*:  
Security Information
Please fill out this information section for security verification.
Date of Birth*:  
Driver License #*:  
Mother's Maiden Name*:  
Amount of Last Deposit*:  
Account Number* Account Type Access Level Access Level Description
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 Client Information section above.

Full Access: View account(s) and make all online transactions including transfers.

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

Signature and Disclaimers
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 Farmers Bank & Capital Trust Co. Upon approval you will be notified via e-mail that your application has been accepted and you will be provided with the instructions necessary to complete the “First Time User” login process. During that process you will be presented with your Internet Banking Agreement and Disclosure Statement (Agreement) which you will need to “Accept”. You may print a copy to retain for your records.

This Agreement represents all of the terms and conditions agreed to in conjunction with the use of Internet Banking, and includes any other documents or disclosures executed pursuant to this agreement, state or federal law. I agree that I will not release my Login ID and password to anyone and that it is my responsibility to maintain the confidentiality of my Login ID and password to prevent unauthorized use. I certify that I am authorized to sign on the accounts listed above. I understand that I am responsible for all charges incurred through the use of this Internet Banking and Internet Bill Pay Service. I understand that I may incur a fee from my cell phone provider for Internet usage capabilities on my phone. Such fees will be charged as per the agreement with my cell phone provider and not Farmers Bank & Capital Trust Co.
 
*Signature: *Date:
  (Type your full name)   (Today's Date)