First State Bank Holly Springs Enrollment Form
*Required Fields:
Login Information
Your Login Name must be between 4 and 12 characters long. The user ID must be unique to our system.
Desired Login Name*:
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*:
Social Security #*:
Address*:
Address:
City*: State*: Zip Code*:
Home Phone*: Work Phone:
Mobile Phone:
Email Address*:
Signature & Disclaimers:
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*Signature: *Date:
  (Type your full name)   (Today’s Date)