Online Banking Enrollment Form
Customer Information
  * denotes required field
First Name*: Middle Initial: Last Name*:
Business Name:
Social Security: TIN (if business):
City*: * Zip Code*:
Home Phone*: Mobile Phone:
Work Phone: Ext:
Email Address*: Bank Use Only:
Driver License #*: Date of Birth*:  
Motherís Maiden Name*: Amount of Last Deposit or Loan Payment*:
User Name

Please enter your desired User Name and Temporary Password. 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`~!@#$%^&*()_+-={}|[]:?;?<>?,./\ If the User Name you have requested is not available, Community Bank of Louisiana will provide a similar but alternate User Name for you. Passwords must be 4 to 15 characters and must contain at least one number.

User Name*:
Temporary Password*:
Account Access Information
Please provide the Account Number, Account Type and Access Level for each account that you wish to access using Online Banking. All accounts must have the same ownership as the information provided in Customer Information above.
Account Number* Account Type Access Level Access Level Description

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

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

How did you hear about our Online Banking?
Please let us know how you heard about us.
Signature & Disclosures
  Signature*: Date*: