This Auto-Enrollment Form allows consumer account holders to initiate Valley Republic Bank Online access. Upon submission of this form, your information will be verified. You will receive an email from Valley Republic Bank when your Valley Republic Bank Online service is ready for your use. Thank you!

*Required Fields
  Login Information
 
Please enter your desired User Name. Each User Name must be unique. Your User Name can contain up to 15 characters consisting of letters, numbers and symbols. You may choose any of these 'special' characters`~!@#$%^&*()_+-={}|[]:?;?<>?,./\
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 or TIN#*:
Address*:
Address:
City*:
State*:
Zip Code*:
Primary Phone*:
Work Phone: Ext:
Cell Phone:
Email Address*:
  Security Information:
 
Please fill out this information for security verification
Date of Birth*:  
Mother's Maiden Name*:  
  Signature:
 
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 Valley Republic Bank.
*Signature: *Date:
  (Type your full name)   (Today's Date)
 
 
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