Account Application

* Asterisk denotes a required field.

Type of Account

Checking

Savings

Product Ownership *

Single

Joint (Right of Survivorship)

How will the account be used?

Information Regarding Applicant

First Name *

Last Name *

Phone *

Email *

Date of Birth (MM/DD/YYYY) *

Driver's License or State ID Number *

Driver's License or State ID Number Issue Date (MM/DD/YYYY) *

Driver's License or State ID Number Expiration Date (MM/DD/YYYY) *

Driver's License or State ID Number State Issued *

SSN (Last 4 Digits) *

Mother's Maiden Name *

Current Address *

Current Address City *

Current Address State *

Current Address Zip *

How Long at Current Address? *

IF AT CURRENT ADDRESS LESS THAN 5 YEARS:

Previous Address

Previous Address City

Previous Address State

Previous Address Zip

Occupation *

Present Employer *

I authorize you to request and obtain one or more credit reports about me from one or more credit reporting agencies for the purposes of considering my application for the Account, reviewing or collecting any Account opened for me, or for any other legitimate business purpose. I authorize you to disclose information about my account to a credit reporting agency if my Account was closed because I have abused it.

Please pick a location to come in person and sign permanent paperwork. *

You are authorizing Farmers & Merchants to send you electronic statements and notices.

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