GenGold® Account Application

Application Details

• Application Type *

  Individual Joint

Customer Information

Primary Applicant

• Last Name *
• First Name *
• Middle Initial
• Address *
• City/State/Zip *
• Phone *
• Email *

Joint Applicant #1

• Last Name
• First Name
• Middle Initial

Joint Applicant #2

• Last Name
• First Name
• Middle Initial

Please Review & Initial:

• I accept the 30-Day GenGold® Free Trial Offer. I understand I can activate my complementary Identity Theft & Security Center Program Featuring restoration Rescue® and that I will have access to all of the membership benefits included with the program. After the 30-Day Free Trial, I understand my account will be debited each statement cycle in the amount of $5.00. I also understand that I can notify the Bank and opt out of the Program and membership fee at any time.

I (We) hereby accept the offer of Fowler State Bank to participate in the benefits program offered by Generations Gold Inc. I (We) agree to pay the monthly fees as noted above and on the bank's Fee Schedule which may change without notice. I (We) understand that this financial institution makes no representation, expressed or implied, regarding the quality of service and products provided by the participants and shall have no liability in connection therewith. All liabilities, claims, damages and demands are the sole and direct responsibility of Generations Gold and its independent benefits program. I (We) hereby authorize Fowler State Bank to release any information deemed necessary for participation in the GenGold® program. I (We) understand that the benefits and services are provided by Generations Gold Inc., a fully independent benefits provider and not Fowler State Bank.

• Signature *