Internet Deposit Account Application
Privacy Policy:  Our privacy policy protects the privacy of your personally-
identifying information that you provide us online.
Applicants must reside in the State of Kansas
Important Information about Procedures for Opening a New Account
Identification Procedures Requirements:  To help the government fight the funding
of terrorism and money laundering activites, Federal law requires all financial
institutions to obtain, verify, and record information that identifies each person who
opens an account.
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's license or other identifying documents.
Security Notice:  You should ONLY fill out this deposit application on-line if you
are using a browser, such as Netscape or Explorer, with the latest security
enhancements.  If you don't have the latest version, download a copy now.  This form
is NOT cached (saved in your computer's memory) when you Quit your browser.
Instructions:
1.  Print this deposit application and gather the information you'll need.
2.  Fill out the application, print it out and fax it to (785) 628-2476
3.  Upon approval of your application, the account documentation will be sent via-mail or
if you choose, stop by one of our convenient locations to complete the forms.
4.  For your security, funds will not be released until the proper signed documentation
is received by First National Bank.
A Valid Social Security Number is required to apply.  Please review and gather the
information you will need before completing this form.
		Deposit Account Request
	Type of Application:
	□ Individual Account  □ Joint Applicant  □ Payable on Death
		Type of Account
	□ Personal Checking			□ Interest Checking
	□ Super Interest Checking			□ Money Market
	□ Investor Money Market			□ Savings
	□ Certificates of Deposit			Certificate Term ____ months
	Opening Deposit $_____________
	Primary Applicant
	First Name		Middle Initial		Last Name
	Date of Birth		Social Security No.		No. of Dependents
	Driver's License No.		Driver's License State		Your E-Mail Address
	Home Phone		Best Time To Call		Work Phone
	Joint Applicant
	First Name		Middle Initial		Last Name
	Date of Birth		Social Security No.		No. of Dependents
	Driver's License No.		Driver's License State		Your E-Mail Address
	Home Phone		Best Time To Call		Work Phone
	Your Residence
	Present Street Address			City	State	Zip
	Years at Address
	Your Employment
	□ Employed □ Self-Employed □ Retired □ Unemployed □ Student
	Your Present Employer			Phone
	Street Address			City	State	Zip
	Years at current employer		Your Position		Gross Monthly Income
	Payable on Death Beneficiary
	First Name		Middle Initial		Last Name
	Date of Birth			Home Phone
	Work Phone			Best Time To Call
Applicant(s) Statement
I/We certify that all information contained herein is accurate and complete toe the best of my knowledge.
I/We authorize First National Bank to obtain a copy of my current credit report as a condition of acceptance
of this application.
I/We acknowledge that this application is subject to approval by First National Bank.  Should my request be
approved, I/We agree to give First National Bank written notice immediately upon change of my name, address,
employment or any other pertinent information contained herein.
For more information about
First National Bank products and services
	Call:			Fax:
	785-628-2400			785-628-2476