Checking/Savings 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 Field

General

Are you applying for an individual or joint account?

Primary Account Holder

If mailing address is different than street address.

Joint Account Holder

Account Holder

Mailing address is different than street address:

Add Another Account Holder

Ownership

Ownership type

If payable on death, enter beneficiary information.

Add Another Beneficiary

Opening Deposit

Products and Services Needed

A Mediapolis Savings Bank representative will be contacting you about your selection above to complete the account opening process.

How would you initially prefer to be contacted?

The purpose of this questionnaire is to begin the application process. All applications are subject to approval.

Endorsement

By submitting this application, I certify that I/we provided the information required and that I am at least 18 years of age and live in the US. I agree that I may receive electronic communications delivered to the e-mail address I provided.