The Bank of Burlington
The Bank of Burlington
  This Enrollment Form allows customers a convenient way to enroll in The Bank of Burlington's Online Banking. Upon submission of this form, your information will be verified. A representative from The Bank of Burlington will contact you by phone once your Online Banking service is ready for your use. Thank you!

If you would like to sign up as a business or commercial account, please stop in and we'll be happy to get you set up.

*Required Fields
  Login Information
 
Please enter your desired User Name. Each User Name must be unique. Your User Name must be at least 6 characters, cannot be more than 15 characters, must contain at least one number and at least one lowercase character.
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*:  
 
  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 The Bank of Burlington.
*Signature: *Date:
  (Type your full name)   (Today's Date)