DEPOSIT ACCOUNT APPLICATION

Important Information About Procedures For Opening A New Account :

(PATRIOT ACT)
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

What this means for you: When you open an account, we will ask you for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

* Required Fields

Please choose the type of account you are applying for:	Please Select Checking Now ITA (MMDA) Savings
Primary Account Holder Information
*First Name:
Middle Initial:
*Last Name:
*Social Security Number:
*Drivers License or State Issued ID Number
*State Issued	Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska New Hampshire New Jersey New Mexico Nevada New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennesse Texas Utah Vermont Virginia Virgin Islands Washington Washington D.C. West Viginia Wisconsin Wyoming
*Date of Issuance:
*Date of Expiration:
*Home Phone:
Cell Phone:
*Work Phone:	Ext:
*Date of Birth:
Occupation:
Employer:
*Mother's Maiden Name:
Joint Account Holder Information (if applicable)
	Check here if there is a joint applicant
First Name:
Middle Initial:
Last Name:
Social Security Number:
Drivers License or State Issued ID Number
State Issued	Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska New Hampshire New Jersey New Mexico Nevada New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennesse Texas Utah Vermont Virginia Virgin Islands Washington Washington D.C. West Viginia Wisconsin Wyoming
Date of Issuance:
Date of Expiration:
Home Phone:
Cell Phone:
Business Phone:	Ext:
Date of Birth:
Occupation:
Employer:
Mother's Maiden Name:
Address Information
*Street Address:	PO Box will not be accepted
*City:
*State:	Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska New Hampshire New Jersey New Mexico Nevada New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennesse Texas Utah Vermont Virginia Virgin Islands Washington Washington D.C. West Viginia Wisconsin Wyoming
*Zip:	- Zip Plus Four:
*E-Mail Address:
Mailing address if different from above:
Mailing Address:
City:
State:	Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska New Hampshire New Jersey New Mexico Nevada New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennesse Texas Utah Vermont Virginia Virgin Islands Washington Washington D.C. West Viginia Wisconsin Wyoming
Zip:	- Mailing Zip Plus Four:
Ownership	Ownership Options Single Owner (individual) Joint (with right to survivorship) Joint (with no right to survivorship)
Account Preferences

	Visa Check Card (Checking and NOW Accounts only) PIN (4 digits) Daily ATM Limit (Subject To Approval) Daily Point of Sale Limit (Subject To Approval) Number of Cards Name(s) on Cards
	Would you like us to place a Check Order for you? (free starter box with opening new account)
Taxpayer Identification
	As a condition of acceptance of my deposit application, I authorize you to obtain a copy of my current credit report and subsequent reports for the purpose of an update, renewal or extension of credit.
	I am not subject to backup withholding, because I am exempt from backup withholding, or because I have not been notified by the IRS that I am subject to backup withholding as a result of failure to report all interest or dividends, or because the IRS has notified me that I am no longer subject to backup withholding.
	I am subject to backup withholding.
	I am not a United States citizen or resident.
	I certify under penalties of perjury that the statements contained in this section are correct.
	By submitting this application, I certify that I/we gave truthfully and fully provided the information required and that I am at least 18 years of age and live in the US. I certify that I have read and agreed to all the Terms & Conditions, Disclosures and Privacy Policy. I agree that I may receive electronic communications posted on the Brunswick State Bank Web Site or delivered to the e-mail address I provide, including information required by various laws and regulations. I authorize Brunswick State Bank to access my credit bureau information, check my employment, and report to credit reporting agencies Brunswick State Bank's experience with me.
	I would like to come in and sign my Signature Card and make my deposit. We will contact you upon account approval to schedule a time that is convenient.
	I would like for my Welcome Kit to be mailed to me and I will complete my signature card and send in a deposit.

All Applications Are Subject To Approval.