To enroll for Millennium Bank Consumer On-Line Banking please print one form for each applicant, choose from the list of services below, complete your personal information and fax to 847-296-9501.

During banking hours, we will process this enrollment form and send you an e-mail letting you know when you are able to log into our system. Included in this e-mail will be your user name and a temporary password.

If you have any questions, please contact a Personal Banker at 847-296-9500.

On-Line Banking only ______ On-Line Banking with Bill Pay   ______

Customer Name(s): __________________________________________________________

Address: __________________________________________________________________

City: ____________________________________________

State:  __________      Zip:  _________

Home Phone:  _________________ Work Phone: _________________

Cell Phone: ________________

Social Security Number:  __ __ __ -  __ __ -  __ __ __ __

E-Mail Address: ____________________________________________________________

Checking Account Number:  _________________________ 

Certificate of Deposit:  _________________

Savings Account Number: ____________________  

Loan Account:  ____________________________              

________________________________________________________________________

Signature of Authorized Signer(s)                                                                     Date