New Account Application

If you have any questions, feel free to contact First State Bank.

Acct. Holder Info PRIMARY OWNER JOINT OWNER
Name
Business Name
D.O.B.
Social Security # /TIN
Street Address
Mailing Address
City, State, ZIP
Driver's License Number
Employer
Home Phone
Work Phone

OWNERSHIP OF ACCOUNT
Personal Accounts
Individual Joint with Survivorship                                   
Commercial Accounts
Sole Proprietorship Corporation Profit Corporation Non-Profit Partnership
   
Organization Other

CHECK ONE OR MORE OF THE ACCOUNTS BELOW TO APPLY FOR:
Regular
Savings		 Interest
Checking		 Free Checking Senior Checking First Club Account
First Package Account Small Business
Checking		 Business Analysis Checking
Regular Savings Money Market
Savings		 Certificate of Deposits IRAs    
Business
Savings		 Business Money Market Savings

CHECK ONE OR MORE OF THE SERVICES BELOW TO APPLY FOR:
Internet Banking First
ATM Card		 First
Check Card		 Direct Deposit Safe Deposit Box

INSTRUCTIONS: The above information is required to apply for any new account with First State Bank. For validity reasons, our institution will not accept an application form via the Internet, e-mail, or fax. If you have any questions, please contact us at (479) 498-2400, or by e-mail at info@fsbmybank.com.

In order for us to process your application correctly, we may need to contact you to verify some of the information or request more necessary documentation. This information will also allow us to better satisfy our regulatory requirements to "KNOW YOUR CUSTOMER." We appreciate you supplying the information for that purpose.

By signing below, I hereby certify that everything I have stated above is correct. You may keep this application whether or not it is approved. By signing below, I authorize
you to check my credit and employment history and verify other information which I have provided you.

Phone:   Email:
    Date:
Signature      
         
Phone:   Email:
    Date:
Signature      

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Complete, print out, sign and mail to the address shown below:

First State Bank
P.O. Box 10610
Russellville, AR. 72812