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New Account Form

To begin, please fill out the fields in the form below. Someone from Customer Service will contact you within one business day to complete the process.

This form uses 256 bit SSL encryption, ensuring that no one else will see your personal information while it is in-transit. Please view our Privacy Policy for more information.

* Required field

Account Type (please select one) *

Individual Joint

Are you a new customer *

Yes No

*Per government regulations (COPA), we cannot open accounts online for children under the age of 18. Please complete the form by filling in the parent’s information and we will contact you for the minor’s information.

Select the account(s) for which you are applying *

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING AN ACCOUNT—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 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.

Personal Information

Full Name (First, MI, Last) *

Social Security Number *

Why do we ask?

In order to properly verify your identity, federal law requires we ask for a government- issued identification number, such as your Social Security number. This information is used solely for the identity verification. Your Social Security number will not be used for any other purpose.

Date of Birth
MM/DD/YY *

Home Phone *

Daytime Phone

Mothers Maiden Name *

Drivers License Number *

State of Drivers License *

Drivers License Issued
MM/YYYY *

Drivers License Expiration
MM/YYYY *

Email Address *

Address Information

Residential Address
(Not a P.O. Box) *

City *

State *

Zip *

Use residential address for mailing address

Mailing Address

City

State

Zip

Employment Information

Current Employer *

# of Years with Current Employer

JOINT - Personal Information

Joint Application Name (First, MI, Last) *

Social Security Number *

Why do we ask?

Date of Birth MM/DD/YYYY *

Home Phone *

Daytime Phone

Mother’s Maiden Name *

Drivers License Number *

State *

Drivers License Issued
MM/YYYY *

Drivers License Expiration MM/YYYY *

Email Address *

Address Information

Residential Address (Not a P.O. Box) *

City *

State *

Zip *

Employment Information

Current Employer

# of Years with Current Employer

How did you heart about us?

Newspaper

Radio

Search Engine

Billboard

Website

Referred By

Other

Questions/Comments

Your Message

Disclosures

Have you had a transaction account at this or another financial intermediary within 12 months before making this application? *

Yes

Have you had a transaction account closed by a financial intermediary without your consent within 12 months before making this application? *

Yes

Have you been convicted of a criminal offense because of the use of a check or other similar item within 24 months of making this application? *

Yes

IMPORTANT

Please read the following disclosures before accepting. I/we have read and agree to the terms and conditions shown above and agree to conform to the bylaws and any amendments of the bank. I certify that statements on this application are true and complete.

By checking “I accept”, you acknowledge you have read and agree to the Account Agreement.

I Accept (Primary)

I Accept (Joint)

Check if under the age 18. If so, parent or guardian is required to sign as joint holder.

First State Bank Southwest reserves the right to use the above information to obtain verifications of identity and background before opening any accounts. We may also access information about you from a consumer reporting agency, such as a copy of your credit report, before opening any account. By submitting this form, I/We grant full permission to do so.

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