Mercantile Checking, Savings, and Certificate of Deposit Account
Application
To apply for your account(s), please completely fill out the application,
print it and mail it with your opening
deposit instructions and photocopies of your valid driver's license to:
Cyber Banking
Mercantile Bank
P.O. Box 371
Quincy, IL 62306
Upon approval of your
application and receipt of your opening deposit, Mercantile will open the
account(s) requested and send you a
receipt and other important information about your account(s). Accounts opened
will be subject to Mercantile Bank's
rates, fees and balance waiver requirements. Your opening deposit should be
made payable to Mercantile Bank.
Note: All non-local deposits must be sent by wire transfer or other electronic
transfer. If you have any questions regarding
this application, please call us at 1-800-405-6372 and ask for Customer Service,
or e-mail us.
NOTE:
If you would
like to name a beneficiary or have any other special account title requests,
please attach a separate sheet
with your instructions and enclose any supporting documents necessary.
Checking, Savings, and Certificate of Deposit Account Applicationecking and Savings Application
I.
ACCOUNT
SELECTION(S)
Checking
Account:
Type
of Account to Open
Initial
Deposit
(min. opening deposit of $100)
Choose
one of the following for your account: Mercantile MasterMoney Card
(An ATM card that works like a check anywhere MasterCard
is accepted) Mercantile ATM Card
(Get cash at any ATM machine where you see the
Cirrus or Shazam logos!)
Bank
Use Only
Savings
Account:
Type
of Account to Open
Initial
Deposit:
(min.
opening deposit of $50 for Statement and DreamBuilder Savings, $25 for Pennywise
Savings and $500 for Savings Special Edition)
Bank
Use Only
True Blue Money Market Account:
Check Here to Select this Account
Initial
Deposit:
(min. opening deposit of $1,000)
Bank
Use Only
CD
Time Deposit Account:
Type
of Account to Open
Initial
Deposit:
(min opening deposit of $1,000)
Bank
Use Only
How do
you want your interest paid?
Keep my money working - add to my principal
Send me a quarterly check
College
Saver CD:
Type
of Account to Open
Initial
Deposit
(min opening deposit of $100)
Bank
Use Only
TOTAL NOTE: All non-local deposits must be sent by wire
transfer or other electronic transfer.
(This is your total opening deposit amount for
all accounts opened above.)
Bank
Use Only
II.
ACCOUNT HOLDER(S) INFORMATION
Primary
Applicant's Information:
(include suffix (Jr., Sr.) if applicable)
Prefix
First
Name
MI
Last
Name
Suffix
Home
Phone
Marital
Status
Married
Separated
Unmarried
Date
of Birth
/
/
Social Security Number
Address
City
State
ZIP
Own
Rent
No
of years:
E-mail:
Joint
Applicant's Information: (include suffix
(Jr., Sr.) if applicable)
Prefix
First
Name
MI
Last
Name
Suffix
Home
Phone
Marital
Status
Married
Separated
Unmarried
Date
of Birth
/
/
Social Security Number
Address
City
State
ZIP
Own
Rent
No
of years:
E-mail:
III.
EMPLOYMENT INFORMATION
Primary
Applicant's Employment:
Check if self-employed
Name
of Employer
Address
City
State
ZIP
Phone
Type
of Business
Position/Title
Years
on the job
Years
in this
Profession
Joint
Applicant's Employment:
Check if self-employed
Name
of Employer
Address
City
State
ZIP
Phone
Type
of Business
Position/Title
Years
on the job
Years
in this
Profession
IV.
PERSONALIZED CHECK ORDER INFORMATION
I (we) would like to receive checks for this account (complete
the area below)
I (we) do not wish to receive checks for this account (move
to Section V.)
Please list your personal
information as you would like it to appear on your printed checks. Any
optional fields left blank will not appear on your checks. You will receive
your checks in the mail 2-3 weeks after we receive your deposit.
Applicant's Name
OPTIONAL
FIELDS
Joint Applicant's Name
Phone Number
Street Address
Applicant's
ID (Driver's License, SSN, etc.)
City
State
ZIP
Joint
Applicant's ID (Driver's License, SSN, etc.)
Additional Instructions:
V.
CERTIFICATION For
Social Security Number verification purposes, please read and sign the
following.
Under
penalties of perjury, the undersigned certifies that: 1) the number
on this form is my correct taxpayer identification number: (TIN) and
2) I am not subject to backup withholding because one of the following
applies: I have not been notified by the Internal Revenue Service
(IRS) that I am subject to backup withholding as a result of failure
to report all interest or dividends or the IRS has notified me that
I am no longer subject to backup withholding. You must cross out item(
2) above if you have been notified by the IRS that you are currently
subject to backup withholding.
Check
the box which applies:
Foreign
Recipient: I certify that I am neither a resident nor a U.S. citizen
and therefore, I am not subject to backup withholding. Also, I've
provided my permanent address to the bank.
Applied
for TIN: I certify that a TIN has not been issued to me and that
I have applied or intend to apply for a TIN. I understand that this
account is subject to immediate withholding of 31% of any payments
made to me until I provide a certified TIN to the bank. I further
understand that if no TIN is provided within 60 days, the Bank has
a right to close this account and deliver the proceeds to me, less
any penalties and less any amounts withheld pursuant to this provision.
The
certifications above do not apply to all signers. Individual certifications
have been provided by all account owners.
The
Internal Revenue Service does not require your consent to any provisions
of this document other than the certifications required to avoid backup
withholding.
Applicant
Signature
Applicant TIN (Social Security Number/
Tax ID Number)
Joint Applicant
Signature
Joint Applicant TIN (Social Security Number/
Tax ID Number)
VI.
AUTHORIZATION TO OPEN ACCOUNT(S)
ACCOUNT
AGREEMENT: Everything that is stated in this new account application
is correct to the best of my (our) knowledge. I (We) give this information
for the purpose of obtaining the type of account(s) stated on this
application. I (We) authorize the Bank to obtain information concerning
any statements made here; to answer any questions about its credit
experience with me (us); and to share any information obtained concerning
or contained in this application with third parties; including credit
reporting agencies. I (We) understand that a credit report may be
requested in connection with this application.
I (We) authorize
the sharing of this application, any information relating to the
account(s) opened and any information obtained concerning this application
with any of the Bank's affiliates.
JOINT WITH
RIGHT OF SURVIVORSHIP AGREEMENT (if more than one signature): We
intend to and do hereby create a joint account with rights of survivorship.
I (We) understand
and agree that when the Bank opens the account(s) requested, I (We)
will be bound by the terms and conditions governing the accounts
as they may be amended from time to time.
Applicant (or custodian) if UGMA account
Date
Joint
Applicant
Date
Bank
Use Only (Name)
Bank
Use Only (Acct #)
Double check to make
sure the application is completely filled out, print it and sign it, and
mail it with your opening deposit instructions and photocopy(s) of your
valid driver's license to:
Cyber
Banking
Mercantile Bank
P.O.
Box 371
Quincy,
IL 62306
Please Note: All non-local
deposits must be sent by wire transfer or other electronic transfer.
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Checking, Savings, and Certificate of Deposit Account Applicationecking and Savings Application