First National Bank of Plainview
New Account Application

    Checking Account:  Savings Account:  CD Account: 
    

        Date  
  First Name:  Initial:  Last Name: 
Current address:  County: 
  City:   State:  Zip: 
  Phone: (Home) (Work)  Birthday: 
  SS #:   Drivers License #:  State: 
  How long lived here?  Years

  "Previous Address only if less than 2 years at current Address"

  Previous Address: 
              City:  State:  Zip: 
  How long lived there?  Years
  
  Current Employer: 
           Address:    
              City:  State:  Zip: 
  How long worked there?  Years
  
  
  "Credit Reference only if Deposit Account's"   
  
  Credit Reference:
           Loan at:   Phone #: 
       Credit Card: 
          or, Rent: 

 Have you had a Transaction Account at this or Another Financial Institution 
  within 60 Months Before making this Application?  Yes  No 

    If Yes, please name the institution: 
        Is this account still open? Yes  No 
    If Closed, was the account closed without your consent? Yes  No 
         Reason: 

 Have you been convicted of a Criminal offense because of the use of a Check or
      Similar item within 24 Months of making this Application? Yes  No 

If you make a False Material Statement in this Document you Do Not believe to be 
   True, You are guilty of Perjury.
   
Backup Withholding Certifications:
   The Taxpayer Identification number shown above is my correct 
      Taxpayer Indentification Number.   
    Backup Withholding - I am not subject to backup withholding either because 
      I have not been notified that I am subject to backup withholding as a result 
      of a failure to report all interest or dividends, or the Internal Revenue 
      Service has notified me that I am no longer subject to backup withholding.
    Exempt Recipients - I am an exempt recipient under the Internal Revenue 
      Service Regulations.
    Non-Resident Aliens - I am not a United States person, or if I am an 
      individual, I am neither a citizen nor a resident of the United States.
  
Please Note: An Account is not opened until a signed completed application is 
       presented with qualifying deposit and disclosures are delivered to the 
       applicant. First National Bank has the right to deny application.
       

       ______________________________
          Applicant Signature    

If this a deposit type account Print it, and Fax or Mail it.
First National Bank of Plainview
138 W. Broadway
Plainview, Mn 55964
Fax: 507-534-3966

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