Certificate of Deposit Application

To apply, having already read and accepted the account disclosures, simply complete and submit this application. Midwest Community Bank will begin the process with the information provided.

A representative from Midwest Community Bank may contact you to verify your account application. Feel free to contact us with any questions you may have at 815-235-6137.

* = Required Field
We intend to apply for a joint account

Applicant             
Co-Applicant

SECTION A - General Information
Last Name:*
A value is required.		 First Name:*

A value is required.		 Middle Initial:
Home Address :*

A value is required.		 City:*

A value is required.		 State:*
 Zip Code:*

A value is required.
Mailing Address
(if applicable):
 City:
 State:
 Zip Code:
Previous Home Address:
 City:
 State:
 Zip Code:
Home Phone (please include area code):*

A value is required.		 Email Address:*
 Fax:
Date of Birth:*

A value is required.		 Social Security Number:*

A value is required.		 Mother's Maiden Name:*

A value is required.
Drivers License Number:*

 Issue Date:*
 State of
Issuance:*

 Expiration Date:*
Employer:

A value is required.		 Employer Address:
City:
State:
 Zip Code:
Employer Telephone:
Years There:
Position / Title:
Joint Applicant Information
*Note, you do not need to fill out this section unless you are applying for a joint application
Last Name:
 First Name:
 Middle Initial:
Home Address :
 City:
 State:
 Zip Code:
Previous Home Address:
 City:
 State:
 Zip Code:
Home Phone (please include area code):
 Email Address:
 Fax:
Date of Birth:
 Social Security Number:
 Mother's Maiden Name:
Drivers License Number:

 Issue Date:
 State of
Issuance:

 Expiration Date:
Employer:
 Employer Address:
City:
State:
 Zip Code:
Employer Telephone:
Years There:
Position / Title:
SECTION B - Account Information
CD Term:

* Note - The CD Rates and Annual Percentage Yield (APY) may change at any time. For the term you select, you will receive the Rate and APY in affect on the date your account is opened.
CD Interest:
CD Interest:

monthly
quarterly
semi-annually
yearly

MWB Checking Acct Number
(if applicable):
MWB Savings Acct Number
(if applicable):
How Initial Deposit Will Be Made: I will mail a check to Midwest Community Bank
      *Note - If by check the opening date of the CD will be the date we receive the check.
Incoming Wire - (An email will be sent to you with wiring instructions)
Debit my existing Midwest Community Bank account
Account Number
Amount of Initial Deposit:
Please Provide The Following Verification Information:
Name of Current Bank:
 Address of Bank:
 City:
State:
 Zip Code:
 Account Number :
Bank ABA or Routing Number:
Are you a US Citizen?
Yes
No

BY CLICKING ON THE SUBMIT BUTTON BELOW, I (WE) APPLY FOR THE 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 MIDWEST COMMUNITY BANK FOR ANY OF THE DEPOSIT PRODUCTS IS CONDITIONED ON MY (OUR) AGREEMENT TO ABIDE BY ALL TERMS AND CONDITIONS CONTAINED IN THE APPLICABLE DEPOSIT AGREEMENT.
I HAVE READ THE ABOVE STATEMENT AND AGREE TO THE TERMS SET OUT THEREIN.
You must agree to the terms to continue.

I would like to have my disclosures sent to my mailing address.
I would like to have my disclosures emailed to me.