Application
Type of Account
Checking
Savings/Money Market
Both Checking & Savings
Type of Account
Single Owner (individual)
Joint tenants (right to survivorship)
Payable on Death (POD)
Primary Account Owner
*First Name:
Middle Name:
*Last Name:
*Date of Birth (mm/dd/yyyy):
*Social Security Number:
*Address
*City:
*ST:
*Zip:
*Home Phone Number (000-000-0000):
*Work Phone Number (000-000-0000):
How long at this address?
Choose one:
Months
Years
*Previous Address:
*City:
*ST:
*Zip:
How long at this address?
Choose one:
Months
Years
*Driver's License Number:
*State:
*E-mail:
Birth City:
Birth State:
Mother's Maiden Name:
Main use of the account:
Current Employer:
Occupation:
How long at this employer?
Choose one:
Months
Years
*Previous Employer:
*Occupation:
*How long at this employer?
Choose one:
Months
Years
*Work Phone (000-000-0000):
Joint Account Owner
(if you selected joint account ownership)
*First Name:
*Middle Name:
*Last Name:
*Date of Birth (mm/dd/yyyy):
*Social Security Number:
*Address:
*City:
*ST:
*Zip:
*Home/Cell Phone Number (000-000-0000):
*Work Phone Number (000-000-0000):
*Driver's License Number:
*State:
Payable on Death Beneficiary
(if you selected POD ownership)
*First Name:
*Middle Name:
*Last Name:
*Social Security Number:
*Phone Number (000-000-0000):
*Address:
*City:
*ST:
*Zip:
Deposit Information
*Initial Deposit:
$
Initial Deposit Type:
Cash
Check
Taxpayer Identification Number Certification
(Check box for "yes" or leave blank for "no")
The Social Security Number(s) shown above is my correct SSN.
I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the internal revenue service has notified me that I am no longer subject to backup withholding.
I am an exempt recipient under the Internal Revenue Service Regulations.
I am not a United States person, or if I am an individual, I am neither a citizen nor a resident of the United States.
I certify under penalties of perjury the statements checked in this section are true.
I authorize Fidelity State Bank to order a credit report or make such inquires of investigation agencies as the bank deems advisable. I understand that the USA Patriot Act requires the bank to verify that I am not on the OFAC SDN list and that the bank may decline to open the account for any reason.
I would like to access this account through Online Banking.