We intend to apply for joint credit
Applicant One: Applicant Two:
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All applicants must complete Section A.
If you are applying for a consumer deposit account, complete Sections A and B.
If you work in Georgia and reside outside of Georgia please contact us. |
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I am applying for:
(check all that apply) |
DEPOSIT ACCOUNTS
Personal Checking
Small Business Checking
Personal Savings
Business Savings
Debit Card
Business Interest Checking
Commercial Analysis Checking
Commercial Money Market Account
LOAN ACCOUNTS
Consumer Loan
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| SECTION A - General Information |
Last Name:*
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First Name:*
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Middle Initial:*
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Home Address :*
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City:*
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State:
GA |
Zip Code:*
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Mailing Address (if applicable):
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City:
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State:
GA |
Zip Code:
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Previous Home Address:
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City:
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State:
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Zip Code:
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Home Phone (please include area code):*
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Email Address:
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Fax:
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Date of Birth:*
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Social Security Number:*
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Employer:*
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Employer Address:
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City:
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State:
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Zip Code:
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Employer Telephone:
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Years There:
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Position / Title:
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| Previous Employer (if less than 2 years at current employment): |
Previous Employer Address:
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City: |
State:
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Zip Code:
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Joint Applicant Information
*Note, you do not need to fill out this section unless you are applying for a joint application |
Last Name:
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First Name:
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Middle Initial:
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Home Address :
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City:
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State:
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Zip Code:
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Previous Home Address:
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City:
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State:
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Zip Code:
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Home Phone (please include area code):
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Email Address:
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Fax:
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Date of Birth:
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Social Security Number:
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Employer:
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Employer Address:
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City:
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State:
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Zip Code:
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Employer Telephone:
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Years There:
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Position / Title:
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| Previous Employer (if less than 2 years at current employment): |
Previous Employer Address:
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City: |
State:
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Zip Code:
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| SECTION B - Deposit Account Information |
CD Term:
(This is only if you choose a Certificate of Deposit)
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CD Interest:
(This is only if you choose a Certificate of Deposit)
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| Amount of Initial Deposit: |
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| How Initial Deposit Will Be Made: |
I will mail a check to Mountain Valley Community Bank
Incoming Wire
Debit my existing Mountain Valley Community Bank account
Account Number
Debit my current Bank
(You will receive a form for authorization)
Bank Name
Account Number
ABA Number |
| Please Provide The Following Verification Information: |
Name of Current Bank:
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Address of Bank:
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City:
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State:
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Zip Code:
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Account Number :
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GA Drivers License or State Issue ID Number:*
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Are you a US Citizen?
Yes
No |
| NOTE: If you do not have a drivers license or state issued ID, please call one of our Customer Service Representatives at (706) 865 - 1905 |
Nearest Relative Not Living With You:
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Address:
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City:
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State:
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Zip Code:
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Phone Number (including area code):
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| Mother's Maiden Name (for security purposes): |
| The Following Services Are Subject To Credit Approval: |
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*Would you like to apply for an Mountain Valley Community Bank Check Card?:
Yes No
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If so, please pick four numbers for your secret code:
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Please reconfirm your secret code:
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*Would you like to apply for overdraft protection?:
Yes No
If yes, please complete Income Information in Section C of this application
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| BY CLICKING ON THE SUBMIT BUTTON BELOW, I (WE) APPLY FOR THE LOAN AND/OR DEPOSIT PRODUCTS LISTED ABOVE AND CERTIFY THAT ALL INFORMATION PROVIDED ABOVE IS CORRECT AND AUTHORIZE YOU TO CHECK MY (OUR) CREDIT AND VERIFY THE INFORMATION PROVIDED IN THIS APPLICATION. I (WE) ALSO CERTIFY UNDER PENALTY OF PERJURY THAT THE SOCIAL SECURITY NUMBER(S) PROVIDED ABOVE IS/ARE CORRECT AND THAT I AM NOT (WE ARE NOT) SUBJECT TO BACKUP WITHHOLDING UNDER THE INTERNAL REVENUE CODE. I (WE) UNDERSTAND THAT ADDITIONAL INFORMATION MAY BE REQUIRED BEFORE A DECISION CAN BE MADE REGARDING THIS APPLICATION. I (WE) FURTHER UNDERSTAND THAT APPROVAL BY Mountain Valley Community Bank FOR ANY OF THE LOAN OR DEPOSIT PRODUCTS IS CONDITIONED ON MY (OUR) AGREEMENT TO ABIDE BY ALL TERMS AND CONDITIONS CONTAINED IN THE APPLICABLE LOAN AGREEMENT AND/OR DEPOSIT AGREEMENT. I FURTHER AGREE TO RETURN ANY ACCESS DEVICE FOR OBTAINING FUNDS FROM ANY TYPE OF ACCOUNT UPON DEMAND BY Mountain Valley Community Bank. |
| I HAVE READ THE ABOVE STATEMENT AND AGREE TO THE TERMS SET OUT THEREIN. |
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