Deposit Account Inquiry- Fairfax State Savings Bank

This is an application for a joint account.

Applicant Information
First Name
Middle Initial
Last Name
Primary Phone
Home Phone
Work Phone
Cell Phone
Email Address
Date of Birth
Best Time to Contact
Method of Contact
Current Residence
Address Line 1
Address Line 2
Zip
City
State
- My mailing address is different than my address line 1
How long at residence?
Previous Residence
- Address Line 1
- Address Line 2
- Zip
- City
- State
How long at above residence?
Previous Residence
- Address Line 1
- Address Line 2
- Zip
- City
- State
How long at above residence?
Previous Residence
- Address Line 1
- Address Line 2
- Zip
- City
- State
How long at above residence?
Employer Information
Present Employer
Occupation
Time at Current Employer
Years Employed in this Profession

Co-Borrower
First Name
Middle
Last Name
Home Phone
Work Phone
Cell Phone
Email Address
Date of Birth
Best Time to Contact
Method of Contact
My mailing address is the same as the borrower.
Current Residence
Address Line 1
Address Line 2
Zip
City
State
My mailing address is different than my address line 1
How long at residence?
Previous Residence
- Address Line 1
- Address Line 2
- Zip
- City
- State
How long at above residence?
Previous Residence
- Address Line 1
- Address Line 2
- Zip
- City
- State
How long at above residence?
Employment N/A
Current Employer / Source of Income
Occupation
Years at Current Employer
Years Employed in this Profession
Primary Gross Income (annually)
Other sources of income
- Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
- Other Gross Income (annually)
- Source of Other Gross Income
Monthly Mortgage/Rent Payment Amt
Additional Monthly Liabilities

Type of Deposit Account
Please check all of the applicable accounts you would like to open. If you don't currently know what account you would like to open just leave this section blank and a bank representative can discuss with you the available options.
Checking Savings

Checking
Free Checking Super NOW Checking
Other sources of income
- Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
- Other Gross Income (annually)
- Source of Other Gross Income
Monthly Housing Expense

Would you like a debit card?

Savings

Regular Savings Insured Money Market Savings Coverdell Education Savings Account Certificates of Deposit (CDs)

By signing below, I certify that everything I have stated in this Application is correct to the best of my knowledge, you agree that we may verify credit record by any means necessary, including preparation of a credit report by a consumer reporting agency. If signing on behalf of a business or other entity, you also acknowledge that we may verify the creditworthiness of that entity.

Applicant
Date
Co-Applicant
Date

Deposit Account Inquiry

Applicant Information

Current Residence

Previous Residence

Previous Residence

Previous Residence

Employer Information

Co-Borrower

Current Residence

Previous Residence

Previous Residence

Employment N/A

Type of Deposit Account

Checking

Savings