Deposit Inquiry Leave me blank for Consumer Deposit. * Indicates required fieldPrimary Applicant:Full Name (Include Middle Initial) * Date of Birth * Email Address Cell Number * Other Phone Number Other Phone Number Type BusinessHomeWorkPhysical Address * City * State * Zip Code * Mailing Address (if different than above) City State Zip Code Joint Applicant:Full Name (Include Middle Initial) Date of Birth Email Address Cell Number Other Phone Number Other Phone Number Type BusinessHomeWorkPhysical Address City State Zip Code Mailing Address (if different from above) City State Zip Code Contact Information:Enter the location you would like to complete your application When is the best time for us to contact you? Monday – Friday 9am to 5pm Preferred Method of Contact Phone EmailAccount(s) you are interested in: Checking Account Savings Account Certificate Of Deposit eStatements Online Banking Mobile Banking ePay Overdraft Privilege Visa® Debit Card or Mastercard™ Debit Card Visa® Credit Card IRAApplicant questions:Have you had a transaction account at this or another financial intermediary within 12 months of making this application?Applicant* Yes NoJoint Applicant Yes NoName of Financial Institution(s) Have you had a transaction account closed by a financial intermediary without your consent within 12 months of making this application?Applicant* Yes NoJoint Applicant Yes NoName of Financial Institution(s) Have you been convicted of a criminal offense for the use of a check or similar item within 24 months of this application?Applicant* Yes NoJoint Applicant Yes NoName of Financial Institution(s) Important information & signatures:To help the government fight 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 apply to open a new account, we will ask you for your name, physical address, date of birth, social security number, and unexpired government issued photo ID, and other information that will allow us to identify you. We may also ask to see other identifying documents. Acceptable forms of identification needed to open an account are a driver’s license, state ID, passport, military ID, and certain tribal IDs. If you make a false material statement in this document that you do not believe to be true, you are guilty of perjury.The undersigned agrees that all information is accurate and authorizes the financial institution to verify credit and employment history.Applicant Signature * Date * Joint Applicant Signature Date Send Application InformationYour form is being processed.There was an error submitting the form. Thank you for your application! We will be in touch with you within 2 business days. Thank you for choosing Park State Bank.