Business Mobile Deposit Enrollment - First Mid Bank & Trust

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.

"*" indicates required fields

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.

BUSINESS INFORMATION:

Tax ID*

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 Last

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*