Business Account Application

Business Information

Business Name

Tax ID Number

Business Phone Number (###-###-####)

Business Fax Number (###-###-####)

What is the business type?

Is this a hemp related business? Yes No

Address Line 1

Address Line 2

City

State

ZIP

Business Mailing Address

Check this box if the business mailing address is different than the business primary address. Yes, the business mailing address is different.

Mailing Address Line 1

Mailing Address Line 2

City

State

ZIP

Beneficial Ownership

Please list the beneficial owners that have 25% or greater ownership in the business.

Beneficial Owner 1

Beneficial Owner 1 Percent

Beneficial Owner 2

Beneficial Owner 2 Percent

Beneficial Owner 3

Beneficial Owner 3 Percent

Beneficial Owner 4

Beneficial Owner 4 Percent

Signer Information

First Name

MI

Last Name

Suffix

Social Security Number (###-##-####)

Birth Date (MM/DD/YYYY)

Mother's Maiden Name

License or ID Number

State ID Issued

License or ID Expiration Date (MM/DD/YYYY)

License or ID Issued Date (MM/DD/YYYY)

Email Address

Address Line 1

Address Line 2

City

State

ZIP

Employer

Occupation

Daytime Phone Number (###-###-####)

Type of Phone Number

Home Phone Number (###-###-####)

Type of Phone Number

How would you prefer to be contacted?

Co-Signer Information

Please complete this section if a co-signer will be on the account. If the account will not have a co-signer, please skip the Co-Signer Information section.

First Name

MI

Last Name

Suffix

Social Security Number (###-##-####)

Birth Date (MM/DD/YYYY)

Mother's Maiden Name

License or ID Number

State ID Issued

License or ID Expiration Date (MM/DD/YYYY)

License or ID Issued Date (MM/DD/YYYY)

Email Address

Address Line 1

Address Line 2

City

State

ZIP

Employer

Occupation

Daytime Phone Number (###-###-####)

Type of phone number

Home Phone Number (###-###-####)

Type of phone number

How would you prefer to be contacted?

Business Related Information

Is this a cash intensive business? Yes No

Are you accepting credit cards? Yes No

Do you sell money orders, exchange cash or do wires? Yes No

Do you sell lottery tickets? Yes No

Will you cash checks for customers? Yes No

If you are cashing checks, will the checks be greater than $1,000? Yes No N/A

Do you have an ATM on premise? Yes No

If you have an ATM, do you own it? Yes No N/A

If you have an ATM, will the transaction clear through your FSB Account? Yes No N/A

If you have an ATM, will you be filling it from your FSB Account? Yes No N/A

Products and Services Needed

Preferred Location

Please add any notes, comments or additional information here

Authorization

By clicking the "Send Application" button below, the applicant(s) request(s) the described services and agrees to the terms and conditions governing the services, including any fees and charges. The applicant(s) agree(s) that all information is accurate and authorizes the financial institution to verify credit and employment history, if necessary, by any means, including preparation of a credit report by a credit agency. Check the "Yes, I agree to the Terms and Conditions" box to indicate that you (the applicant) have read the agreement and accept its terms.

(The purpose of this questionnaire is to begin the application process. All applications are subject to approval. You will be contacted by a bank representative to finalize the account application.)

Terms and Conditions

Business Truth In Savings Disclosure

Electronic Fund Transfers Disclosure

I agree to the Terms and Conditions.

Yes

I have read the Business Truth In Savings Disclosure. Yes

I have read the Electronic Fund Transfers Disclosure. Yes