FIRST STATE BANK OF NORTHWEST AR

FIRST STATE BANK OF NORTHWEST ARKANSAS

NEW ACCOUNT APPLICATION

Primary Account Holder

First Name:____________________ MI:_____ Last Name:________________________

Address*:_______________________________________________________________

_______________________________________________________________________

SSN: _________________ DOB:__________ Mothers Maiden Name:_______________

Drivers License #: _____________________ Issuing State:_____ Exp. Date: _________

Home #: ______________ Work #: ________________ Cellular #: _________________

Employer & Address: _____________________________________________________

*(Please note: P.O. Box Holders must furnish physical address as well as mailing address)

Secondary Account Holder

First Name:____________________ MI:_____ Last Name:________________________

Address*:_______________________________________________________________

_______________________________________________________________________

SSN: _________________ DOB:__________ Mothers Maiden Name:_______________

Drivers License #: _____________________ Issuing State:_____ Exp. Date: _________

Home #: ______________ Work #: ________________ Cellular #: _________________

Employer & Address: _____________________________________________________

Business Account Holder

Type of Entity:___________________________________________________________

Name:__________________________________________________________________

Address*:_______________________________________________________________

________________________________________________________________________

TIN#: _______________________ Phone #: ___________________________________

Authorized Agents: _______________________________________________________

_______________________________________________________________________

Will this account have Pay-On-Death?_____ If so, please give the beneficiary (ies) name, address, and telephone number:______________________________________________

________________________________________________________________________

Type of Account

____Checking ____Savings ____NOW ____Money Market

____IRA ____Certificate of Deposit ____ Deposit Box

Additional Information:____________________________________________________

I understand that under the USA Patriot Act, this financial institution is obligated to verify the identity of each customer opening a new account, or each new owner being added to a deposit account, and I understand and agree that if the institution is not able to verify the identity of all of the owners of this account within a reasonable time, it may, at any time, in its sole discretion, without providing notice, close the account.

The information I have provided is correct to the best of my knowledge. I authorize First State Bank of NWA to check credit and/or employment history should it deem necessary. Verification of all account information of all account information is provided by ChexSystems.

Signed:________________________________________ Date:_____________________