Account Application  

* indicates a required field

Select an Account:   

Single Owner (individual)  
Joint (right to survivorship)  
In Trust For  

Primary Account Owner  
*Name (First M. Last)     
*Date Of Birth (mm/dd/yyyy)     
*Social Security Number     
*City, State, Zip              
*Home Phone Number     
Work Phone Number  
*Driver's License Number      *State    
*Driver's License Expiration Date (mm/dd/yyyy)     
*Employer Address     
*Employer City, State, Zip              
*Employer Phone Number     
*Date Of Employment (mm/dd/yyyy)     

Joint Account Owner Information  
Name (First M. Last)  
Date Of Birth (mm/dd/yyyy)  
Social Security Number  
Driver's License Number   State
Driver's License Expiration Date (mm/dd/yyyy)  

In Trust For  
Name (First M. Last)  
Social Security Number  
Phone Number  
City, State, Zip    

Deposit Information  
Initial Deposit $  
Initial Deposit Type
Future Deposit Type
Fill out the following information only if depositing via an existing account.
Account Number  

Taxpayer Identification Number Certification
Social Security Number(s) shown above is my correct SSN.
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.
I am an exempt recipient under the Internal Revenue Service Regulations.
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.
I certify under penalties of perjury the statements checked in this section are true.

I authorize Merchants Bank to obtain a copy of my current credit report as a condition of acceptance of this application and for the purpose of extension of or renewal of credit.

* indicates a required field

Please supply Merchants Bank a copy of your current driver's license within 15 days of account opening. Failure to supply this copy may lead to closure of your new account.