FSBT CERTIFICATE OF DEPOSIT Form

Which Branch will be your primary banking location?*
What will be the amount of your Certificate of Deposit?*
($1,000 minimum)
Certificate of Deposit Information: Choose your Certificate of Deposit Term*

6 Month12 Month18 MonthOther / Custom Term
Will this be a Personal or Business Certificate of Deposit?*

PersonalBusiness

Personal Certificate of Deposit Application
You will need to provide the following information for every owner and signer.
1. A U.S. government-issued photo ID (e.g. driver’s license, passport, state or military ID)
2. Proof of Social Security Number
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
SS#*
Phone Number*
Please enter a valid phone number.
Mother’s Maiden Name*
Occupation*
Employer*
Would you like to add a joint owner or authorized signer?*

Yes - Joint owner/co-applicant – has rights of survivorshipYes - Authorized signer – ceases at death of all ownersNo

Co-applicant/Signer Information
Co-applicant/Signer Name

First NameLast Name
Co-applicant/Signer Email
example@example.com
Co-applicant/Signer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Co-applicant/Signer Date of Birth

MonthDayYear
Date
Co-applicant/Signer SS#
Co-applicant/Signer Phone Number
Please enter a valid phone number.
Co-applicant/Signer Mother’s Maiden Name
Co-applicant/Signer Occupation
Co-applicant/Signer Employer

For Individual or Joint Accounts only (not a fiduciary account) Please Provide the following information for your designated beneficiary (or beneficiaries)

	Name	Date of Birth	Relationship
1
2
3
4

2nd Authorized Agent OR Signers Name*

First NameLast Name
2nd Authorized Agent OR Signers Title*
2nd Authorized Agent OR Signers Email*
example@example.com
2nd Authorized Agent OR Signers Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2nd Authorized Agent OR Signers Date of Birth*

MonthDayYear
Date
2nd Authorized Agent OR Signers SS#*
2nd Authorized Agent OR Signers Phone Number*
Please enter a valid phone number.
2nd Authorized Agent OR Signers Mother’s Maiden Name*
2nd Authorized Agent OR Signers Occupation*
2nd Authorized Agent & Signers Employer Name*

Please provide the following information for the ownership of the legal entity.

Certificate of Beneficial Ownership Information:
Name of Person Opening the account: *

First NameLast Name
Provide information on everyone who directly or indirectly owns 25% or more of equity interest of the legal entity.

Owner 1 Information*

	Name	DOB	% of Ownership	SS#
1

Owner 1 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Owner 2 Information

	Name	DOB	% of Ownership	SS#
1

Owner 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Owner 3 Information

	Name	DOB	% of Ownership	SS#
1

Owner 3 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Owner 4 Information

	Name	DOB	% of Ownership	SS#
1

Owner 4 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provide the following information for person responsible for managing the listed legal entity above such as:

(Executive Officer, Senior Manager, Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President, Treasurer, or any other individual who regularly performs similar functions)

Manger of Legal Entity Information*

	Name	DOB	% of Ownership	SS#
1

Manger of Legal Entity Information Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

When would be a good time to contact you about your application?*

MorningAfternoonEveningOther
Should be Empty:

Personal Certificate of Deposit Application

Co-applicant/Signer Information

Business Certificate of Deposit Application

Business Information

Certificate of Beneficial Ownership Information:

Provide information on everyone who directly or indirectly owns 25% or more of equity interest of the legal entity.

Provide the following information for person responsible for managing the listed legal entity above such as: