Consumer Account Application

Opening an Account just got easier!
Apply now, to get started and one of our Customer Service Representatives will contact you.
Please note: To apply online you must be 18 years or older and a legal resident of the United States.

Account Types Deposit Account Certificate of Deposit

Accounts Classic Checking Premier Checking Super Now Checking Money Market Account Savings Debit Card Safe Deposit Box

Account 12 Month CD or IRA 24 Month CD or IRA 36 Month CD or IRA 48 Month CD or IRA 60 Month CD or IRA Other

Other Description

Are you signing individually or with a co-signer? Individual Signer With a Co-Signer

Signer

First Name Middle Name Last Name Suffix Birth Date Social Security Number

ID

ID Type (ie. Driver’s License) ID Number State Issued Date of Expiration

Street Address

Street Address (physical address) City State Zip Code Mailing address is different than street address.

Mailing Address

Mailing Address City State Zip Code

Contact Information

Primary Phone Number Alternate Phone Number E-mail Address

Employment

Employer Name Occupation

Co-Signer

First Name Middle Name Last Name Suffix Birth Date Social Security Number

ID

ID Type (ie. Driver’s License) ID Number State Issued Date of Expiration

Street Address

Street Address (physical address) City State Zip Code Mailing address is different than street address.

Mailing Address

Mailing Address City State Zip Code

Contact Information

Primary Phone Number Alternate Phone Number E-mail Address

Employment

Employer Name Occupation

Beneficiaries

Should the bank need to contact your beneficiary(s), it is in your best interest to provide as much contact information as possible.

Beneficiary

First Name Middle Name Last Name Suffix Birth Date Social Security Number Phone Number Mailing Address City State Zip Code

Special Instructions

In accordance with the USA Patriot Act, our financial institution is required to obtain, verify and record information that identifies each person that has an account. We will ask your name, address, DOB, SSN and other information, including but not limited to a current, non-expired picture identification. We support all efforts to protect and maintain the security of our customers and our country.

Our financial institution verifies all account applicants with eFunds ChexSystems and OFAC.

Per bank policy, Mid America Bank reserves the right to close any/all accounts if proper documentation is not received within 30 days of opening.

Authorization

I authorize Mid America Bank to contact me.