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INTERNET ENROLLMENT FORM
Attention:  Fill in all the information, print and sign the form, and then mail or drop off at any Kentland Bank branch. You may fax form, but original with signature must be sent to bank.
Kentland Bank
P.O. Box 145
Kentland, IN 47951
219-474-5155
Fax 219-474-5071		 Lake Village
P.O. Box 245
Lake Village, IN 46349
219-992-3313
Fax 219-992-2501		 Rensselaer
P.O. Box 164
Rensselaer, IN 47978
219-866-4142
Fax 219-866-4514		 Roselawn
P.O. Box 304
Roselawn, IN 46372
219-345-4646
Fax 219-345-2038
Ownership Information:
  Personal   Business
First Name  
Last Name  
Personal = City of Birth
Business = Security Identifier
e-mail Address  
Social Security #  
Street Address  
City

State
Zip-Plus 4 -
Telephone Number  
List each Account Number and Account Type or write ALL to add all your accounts.
Account Number Account Type
   
   
   
   
   

Do you wish to apply for bill payer which may require additional approval? Yes___ No___

Signature: ______________________________________________________
 
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