Christmas Club Application

Please fill out the information requested on this form to open a Christmas Club account. Information requested is used to open your account, keep you advised of the program, and comply with US law only. Personal information is not provided to third parties for other purposes. All requested information is required to participate.

USA PATRIOT ACT INFO
The USA Patriot Act requires information that verifies each person opening an account. To help the US government for money laundering and terrorism activities, we appreciate your assistance in accurately completing these forms.

Employee Information

* First Name

Middle Name

* Last Name

* Company Name

* Social Security Number

* Date of Birth

* Phone Number

* Email Address

* Current Physical Address

* City

* State

* ZIP Code

Mailing address same as physical address

* Current Mailing Address (if different)

* City

* State

* ZIP Code

Driver's License Information

* Driver's License Number

* Issue Date

* Expiration Date

* Please attach a copy of your Driver's License

Attach Driver's License

Please attach a copy of your Social Security Card

Attach Social Security Card

Payroll Deduction Information

* Amount to be withheld each pay period

* Method for DocuSign

Text

Beneficiary Information

Name

Phone Number

Date of Birth

Address

City

State

ZIP Code

I am a First Community Bank customer and would like to set up automatic transfer of my Christmas Club funds

Signature

* Applicant Signature

* Date

Online Banking

Online Banking

Now Available