To apply for your account, please completely fill out the application, print
it and mail it with your opening
deposit instructions and photocopies of your valid driver's license(s) to:
Cyber Banking
Mercantile Bank
P.O. Box 3455
Quincy, IL 62305-3455
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.
I. ACCOUNT
SELECTION
DreamBuilder
Savings Account:
Initial
Deposit
(min. opening deposit of $50)
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
Social Security Number
Driver's License Number
Date
of Birth
/
/
City of Birth
Mother's Maiden Name
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
Social Security Number
Driver's License Number
Date
of Birth
/
/
City of Birth
Mother's Maiden Name
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
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 appropriate boxes if applicable:
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 3455
Quincy, IL 62305-3455
Please Note: All non-local deposits must be sent by wire transfer
or other electronic transfer.
