Business Account Application

Business Information

(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.

Business Name Tax ID Number Business Phone Number Business Type Street Address City State Zip Code Mailing address is different than street address.

Mailing Address City State Zip Code

Business Type Sole Proprietor Corporation Partnership LLC Non-Profit Other

Authorized Signer Information

Authorized Signer

First Name Middle Initial Last Name Suffix Social Security Number Birth Date Mailing Address City State Zip Code Phone Type 1 Phone Number 1 Phone Type 2 Phone Number 2 Email Type E-mail Address Please do NOT email me important news and updates.

How would you prefer to be contacted? Home Phone Business Phone Cell Phone Email

Other Preference

Products and Services Needed

Account Type

Select additional services needed. Business Money Market Business Savings Certificate of Deposit Online Banking ACH Remote Deposit Capture Mobile Deposit Capture Debit Card for Account Checks for Account

Master Debit Card Account Number Checking Account Number

The purpose of this questionnaire is to begin the application process. All applications are subject to approval. We will contact you once the application has been reviewed.

Endorsement

As a condition of acceptance of my deposit application, I authorize you to obtain a copy of my ChexSystems report to process my new account request. 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 Fiserv web site or delivered to the e-mail address I provide, including information required by various laws and regulations.