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

Account Type

Are you applying for an individual or joint account?

Individual
Joint

Primary Account Holder

First Name Middle Initial Last Name Suffix Social Security Number Birth Date Mother's Maiden Name Driver's License Number State Issued Date of Expiration Issue Date Street Address City State Zip Code

If mailing address is different than street address.

Mailing Address City State Zip Code Home Phone Number Cell Phone Number Work Phone Number E-mail Address Occupation Employer Name

Joint Account Holder

Account Holder

First Name Middle Initial Last Name Suffix Social Security Number Birth Date Mother's Maiden Name Driver's License Number State Issued Date of Expiration Issue Date Street Address City State Zip Code

Mailing address is different than street address:

Mailing Address City State Zip Code Home Phone Number Cell Phone Number Work Phone Number E-mail Address Occupation Employer Name

 Add Another Account Holder

Ownership

Ownership type

Single Owner (individual)
Joint Owner
Payable on Death

If payable on death, enter beneficiary information.

First Name Middle Initial Last Name Suffix Beneficiary Percentage Social Security Number Birth Date Driver's License Number State Issued Date of Expiration Issue Date Street Address City State Zip Code Relationship to holder

 Add Another Beneficiary

Opening Deposit

Deposit Amount Deposit Type

Products and Services Needed

Visa Check Card
Mobile Deposit
E-Statements
Certificate of Deposit
Bill Payment
Online Banking
Would you like us to place a Check Order for you?
Would you like an application for insufficient funds transfer?

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?

Home Phone
Work Phone
Cell Phone
email

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

Endorsement

I certify I am a United States citizen or resident.

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.

Primary Account Holder's Signature Date