Business Name: *

Tax ID Number: *

Business Phone Number: *

Business Fax Number:

What is the business type? * Please Select Sole Proprietor Corporation Partnership LLC Organization or Club Non Profit Municipal Other

If "Other" state the type:

Is this a hemp related business? * Please Select Yes No

Beneficial Ownership - Please list business owner names and percent ownership for each owner:*

Street Address: *

City: *

State: * Please Select Wisconsin Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP Code: *

Mailing Address or PO BOX:

Mailing City:

Mailing State: Please Select Wisconsin Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Mailing ZIP Code:

First Name: *

Middle Initial:

Last Name: *

Suffix: Please Select I II III IV Jr Sr

Social Security Number: * (###-##-####)

Birth Date: * (mm/dd/yyyy)

Mother's Maiden Name:

License or ID number: * (Enter ID number from state-issued ID)

State ID issued: * Please Select Wisconsin Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

License or ID issued date: * (mm/dd/yyyy)

License or ID expiration date: * (mm/dd/yyyy)

Email Address:

Street Address: *

City: *

State: * Please Select Wisconsin Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP Code: *

Employer: *

Occupation:

Daytime Phone Number: *

Type of phone number: * Please Select Mobile Home Work

Home Phone Number:

Type of phone number: Please Select Mobile Home

How would you prefer to be contacted? * Please Select Home Phone Mobile Phone Work Phone Email Other

If "Other" state preference:

Is this a cash intensive business? * Please Select Yes No

Are you accepting credit cards? * Please Select Yes No

Do you sell money orders, exchange cash or do wires? * Please Select Yes No

Do you sell lottery tickets? * Please Select Yes No

Will you cash checks for customers? * Please Select Yes No

If you are cashing checks, will the checks be greater than $1,000? * Please Select Yes No N/A

Do you have an ATM on premise? * Please Select Yes No

If you have an ATM, do you own it? * Please Select Yes No N/A

If you have an ATM, will the transaction clear through your FSB Account? * Please Select Yes No N/A

If you have an ATM, will you be filling it from your FSB Account? * Please Select Yes No N/A

Please add any notes, comments or additional information here: