If you were referred by someone, please let us know who to thank

Firm name

Contact

Title

Contact Street Address

Contact Mailing Address (if different than above)

Number of employees

Headquarters office?
YesNo

Branch office?
YesNo

Please list your legal entity, (Corporation, LLC, etc.)

Telephone

Toll Free

Fax

Email

Company Website

Please check all of the following, which are applicable
We would like our company’s information (per this form) in your publications and on our website.We agree that information can be sent from IBAT & IBAT Services and their affiliates by email.

Description (using key words) of business — 65 words or less (one paragraph only).

Please list two community banks who are customers of your company and their contact information (membership subject to reference verification)

First Reference
Reference 1 Contact Name

Reference 1 Email

Reference 1 Phone

Reference 1 Bank or Company

Reference 1 State

Second Reference
Reference 2 Contact Name

Reference 2 Email

Reference 2 Phone

Reference 2 Bank or Company

Reference 2 State

If insurance-related company, please list A.M. Best rating

If paying via credit card please list name and number to contact for processing once your application is approved