Plains State Bank

COD 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:
   
   
Primary Account Holder Information
*First Name:
Middle Initial:
*Last Name:
*Social Security Number:
*Drivers License Number
*State Issued
*Date of Issuance:
*Date of Expiration:
*Home 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
State Issued
Home Phone:
Business Phone:    Ext:
Date of Birth:
Occupation:
Employer:
Mother's Maiden Name:
   
Address Information
*Street Address:
*City:
*State:
*Zip: -
*E-Mail Address:
Mailing address if different from above:  
Mailing Address:
City:
State:
Zip: -
   
Ownership
 
   
If Payable on Death, Name and Address of Relation...
Name (First, Middle, Last):
Street Address:
City:
State:
Zip: -
Social Security Number:
Relationship:
   
Opening Deposit
*Deposit Amount:
*Deposit Type: