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Please fill out this simple form to begin your switch to Fairfax State Savings Bank.

 
IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING OR CHANGING
AN ACCOUNT WITH FAIRFAX STATE SAVINGS BANK

Section 326 of the USA PATRIOT ACT requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account or changes an existing account. This federal requirement applies to all new customers and current customers. This information is used to assist the United States government in the fight against the funding of terrorism and money-laundering activities.

What this means to you: when you open an account or change an existing account, we will ask each person for their name, physical address, mailing address, date of birth, and other information that will allow us to identify them. We will ask to see each person’s driver’s license and other identifying documents and copy or record information from each of them.
 

Personal and Residential Information
*First Name:   * MI:
*Last Name: 
*Social Security Number: 
*Birthdate:     
E-mail: 
*Home Phone (with area code): 
Cell Phone (with area code): 
Work Phone (with area code): 
Best Method of Contact: 
*Street Address: 
*City: 
*State: 
*Zip Code: 
Length of Residence: 
Mailing Address:  is the same as above     is different (fill in below)
Mailing Address: 
City: 
State: 
Zip Code: 
If you have lived at your current address for less than one year, please provide your previous address below.
Previous Address: 
City: 
State: 
Zip Code: 
   
Employment Information
Employer: 
Position: 
Length of Employment: 
Employer's Address: 
City: 
State: 
Zip Code: 
Previous Employer: 
   
Previous Bank Information
Previous Bank: 
City: 
State: 
   
Certification/Acknowledgement
The undersigned certifies that the information provided is true and correct. The undersigned also acknowledges and agrees that the information provided above may be verified at any time by Fairfax State Savings Bank, either directly or through a credit reporting agency or other data collection bureau.
     
 
Signature   Date
   

 

FDIC
Member FDIC

Fairfax State Savings Bank
 
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