Business Mobile Deposit Enrollment

Please complete the following form to request Business Mobile Deposit services. You must have a business checking account at First Mid Bank & Trust to sign up for Business Mobile Deposit services.

INSTRUCTIONS:

Please verify all information is correct and complete;
Please provide all requested information, including valid US address and phone number;
Submission of completed form constitutes a request for Business Mobile Deposit Services.

* Required field

Business Information

Tax ID*Last four digits

Checking Account Number (1)* Last four digits

Checking Account Number (2) Last four digits

Checking Account Number (3) Last four digits

Checking Account Number (4) Last four digits

Name of Business*

Business Address

Street Address

City

State

Zip Code

Business Phone

Business Fax

Business Email

Applicant's Information

Date of Birth*

Applicant's Name

First Name*

Last Name*

Applicant's Email*

Applicant's Address

Street Address

City

State

Zip Code

Applicant's Mobile Phone

Entry of your name and date below will serve as your electronic signature.

Name (Signature)*

Date*

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