Enter name EXACTLY as it appears on your account.
Account Number:
First Name:
Middle Initial:
Last Name:
If you have a suffix in your name, include it after your last name. For example: Smith Jr
Last 4 digits of social security number: ( XXXX )
Email (disclosure):
Confirm Email:
Cell Phone :( ) -
Providing information on the lines above is my express written consent for Merrick Bank and its service providers to contact me, including by use of auto-dialers and other automated means, in connection with my Account, at the phone numbers and e-mail address provided by me.
Date of Birth (Ex: 11/01/1975): / /
State in which you reside:
Mother's Maiden Name:
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