Secure Home Banking Enrollment Form

14267 Bank Street. Becker, MN 55308
Phone: (763) 262-9888 | Fax: (763) 262-9883

Member Information

Member Account Number:

First Name:

Middle Name/Initial:

Last Name:

Last 4 Digits Of Social Security #:

Birthdate (MM/DD/YYYY):

Email Address:

Email List Request:

Yes, Please add me to your Email list
No, Please do not add me to your Email list

Street Address:



Zip Code:

Home Phone #:

Cell Phone #:

Work Phone #



I would like to receive my statements electronically. I UNDERSTAND THAT IF I UNCHECK THIS BOX, I WILL BE CHARGED A $2.00/MONTH PAPER STATEMENT FEE.

Submit Form

By submitting this request, I acknowledge that I have read and agree to the terms of the Home Banking Disclosure