Black River Country Bank - BRCB Personal Checking/Savings Account Application

Equal Housing Lender | Member FDIC

BRCB Personal Checking/Savings Account Application

Submitter Information

First Name (required)

Last Name (required)

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(required)

Individual

Joint

	First Name	Middle Initial	Last Name

	Date of Birth	Social Security No.	Your E-mail Address

Social Security Card

A scan of the front of your Social Security Card

0 Files uploaded:

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	Driver's License No.	Driver's License State	Issue Date	Exp. Date

Drivers License - Front

A scan of the front of your Drivers License

0 Files uploaded:

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	Primary Phone	Cell Phone

Address Information

Street Address Line 1

Street Address Line 2

City

State

ZIP Code

	First Name	Middle Initial	Last Name

	Date of Birth	Social Security No.	Your E-mail Address

Social Security Card

A scan of the front of your Social Security Card

0 Files uploaded:

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	Driver's License No.	Driver's License State	Issue Date	Exp. Date

Drivers License - Front

A scan of the front of your Drivers License

0 Files uploaded:

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	Primary Phone	Cell Phone

Address Information

Street Address Line 1

Street Address Line 2

City

State

ZIP Code

Checking Accounts

YOU. EMBARK. Checking

YOU. ASPIRE. Checking

Savings Accounts

YOU. SECURE. Savings

Money Market Accounts

YOU. ATTAIN. Money Market

Debit Card

(required)

I/We AGREE with the above statements.

[{"context":"terms","text":"<p><strong>Important Information about Procedures for Opening a New Account<\/strong><br \/>\nIdentification Procedures Requirements: To help the government fight the 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.<\/p>\n\n<p>What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver&#39;s license or other identifying documents.<\/p>\n\n<p><strong>Security Notice:<\/strong><br \/>\nYou should ONLY fill out this Application on-line if you are using a browser with the latest security enhancements. If you don&#39;t have the latest version, download a copy now.<br \/>\n<br \/>\n<strong>Instructions:<\/strong><br \/>\n<strong>1.<\/strong> Complete Application and click &quot;Submit Application&quot;.<br \/>\n<strong>2.<\/strong> To safeguard your privacy, QUIT your browser and restart it again after using this form. This form is NOT saved in your computer&#39;s memory when you quit your browser.<br \/>\n<strong>3.<\/strong> We will contact you with the location of our closest office for you to sign a signature card. You may also be requested to provide photocopies of your Social Security card and Driver&#39;s License, or other documentation.<\/p>\n","title":" ","inputid":"boqR9"},{"context":"text","text":"Account Titling Information","inputid":"rDUSd"},{"context":"radio","inputname":"","mandatory":"true","comment":"","options":["Individual","Joint"],"inputid":"OaRcy","otheroption":"false"},{"context":"text","text":"Primary Joint Account Holder Information","inputid":"urlgY"},{"context":"table","inputname":"","mandatory":"true","comment":"","headernames":["First Name","Middle Initial","Last Name"],"tableReqs":{"AJgkd":{"BUhZW":false},"mlZNU":{"BUhZW":false},"NVUjg":{"BUhZW":false}},"tableCols":{"AJgkd":"First Name","mlZNU":"Middle Initial","NVUjg":"Last Name"},"tableRows":{"BUhZW":""},"rownames":[""],"rownumber":1,"inputtype":"text","inputid":"pECCF"},{"context":"table","inputname":"","mandatory":"true","comment":"","headernames":["Date of Birth","Social Security No.","Your E-mail Address"],"tableReqs":{"OaYgx":{"p3Hde":false},"WizBv":{"p3Hde":false},"6Qj4H":{"p3Hde":false}},"tableCols":{"OaYgx":"Date of Birth","WizBv":"Social Security No.","6Qj4H":"Your E-mail Address"},"tableRows":{"p3Hde":""},"rownames":[""],"rownumber":1,"inputtype":"text","inputid":"qUSZO"},{"context":"upload","comment":"A+scan+of+the+front+of+your+Social+Security+Card","inputname":"Social+Security+Card","mandatory":"false","uploadlimit":"1","inputid":"hlajH"},{"context":"table","inputname":"","mandatory":"true","comment":"","headernames":["Driver's License No.","Driver's License State","Issue Date","Exp. 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Date"],"tableReqs":{"Oranu":{"pFYw8":false},"lY2bh":{"pFYw8":false},"kk42o":{"pFYw8":false},"v1PMy":{"pFYw8":false}},"tableCols":{"Oranu":"Driver's License No.","lY2bh":"Driver's License State","kk42o":"Issue Date","v1PMy":"Exp. Date"},"tableRows":{"pFYw8":""},"rownames":[""],"rownumber":1,"inputtype":"text","inputid":"dUWaK"},{"context":"upload","comment":"A+scan+of+the+front+of+your+Drivers+License","inputname":"Drivers+License+-+Front","mandatory":"false","uploadlimit":"1","inputid":"Yz9TQ"},{"context":"table","inputname":"","mandatory":"true","comment":"","headernames":["Primary Phone","Cell Phone"],"tableReqs":{"pOvxj":{"Zi89l":false},"btmhd":{"Zi89l":false}},"tableCols":{"pOvxj":"Primary Phone","btmhd":"Cell Phone"},"tableRows":{"Zi89l":""},"rownames":[""],"rownumber":1,"inputtype":"text","inputid":"l125D"},{"context":"address_us","comment":"","inputname":"Address+Information","mandatory":"false","mask":"true","inputid":"9npXF"},{"context":"text","text":"I\/We would like to apply for the following account(s):","inputid":"34D8U"},{"context":"checkbox","inputname":"Checking+Accounts","mandatory":"false","comment":"","options":["YOU. EMBARK. Checking","YOU. ASPIRE. Checking"],"inputid":"dj1d4","otheroption":"false"},{"context":"checkbox","inputname":"Savings+Accounts","mandatory":"false","comment":"","options":["YOU. SECURE. Savings"],"inputid":"FvZmZ","otheroption":"false"},{"context":"checkbox","inputname":"Money+Market+Accounts","mandatory":"false","comment":"","options":["YOU. ATTAIN. Money  Market"],"inputid":"PRXMr","otheroption":"false"},{"context":"radio","inputname":"Debit+Card","mandatory":"false","comment":"","options":["1","2"],"inputid":"nvFBF","otheroption":"false"},{"context":"text","text":"","inputid":"QqKqv"},{"context":"checkbox","inputname":"","mandatory":"true","comment":"","options":["I\/We AGREE with the above statements."],"inputid":"xX5DQ","otheroption":"false"}]