Name of Business:
(For Corporations, as shown on Articles of Incorporation)
For Corporations Only
Name of Account:
(Example: ABC, Inc. Employee's Retirement Trust)
Business Street Address:
City: State: Zip:
Mailing Address: Street:
City: State: Zip:
Business Phone: Fax Phone:
Website:
Tax ID Number: Type of Business:
Contact Person: Phone Number:
Email:
Statement: Mailed Held for Pick-up
Statement Mailing Address: Business Other
Former Banking Relationship:
Referred By:
Personal Information on Each Signer
Name:
Name:
Title:
Title:
Authorized to Withdraw Funds from this Account? Yes No
Authorized to Withdraw Funds from this Account? Yes No
Driver's License Number:
Driver's License Number:
Social Security Number:
Social Security Number:
Date of Birth:
Birth Place:
Date of Birth:
Birth Place:
Mother's Maiden Name:
Mother's Maiden Name:
Home Telephone:
Home Telephone:
Name:
Name:
Title:
Title:
Authorized to Withdraw Funds from this Account? Yes No
Authorized to Withdraw Funds from this Account? Yes No
Driver's License Number:
Driver's License Number:
Social Security Number:
Social Security Number:
Date of Birth:
Birth Place:
Date of Birth:
Birth Place:
Mother's Maiden Name:
Mother's Maiden Name:
Home Telephone:
Home Telephone:
Name:
Name:
Title:
Title:
Authorized to Withdraw Funds from this Account? Yes No
Authorized to Withdraw Funds from this Account? Yes No
Driver's License Number:
Driver's License Number:
Social Security Number:
Social Security Number:
Date of Birth:
Birth Place:
Date of Birth:
Birth Place:
Mother's Maiden Name:
Mother's Maiden Name:
Home Telephone:
Home Telephone:
I understand that this is an application for an account(s) with <bankname> and is subject to approvalEverything that I have stated in this account agreement is correct to the best of my knowledgeYou are authorized to check credit, company history and an inquiry into past banking relationships.
APPLICANT BACKUP WITHOLDING CERTIFICATION
Taxpayer ID Number: (If Taxpayer ID is same as your SSN, leave blank)
Certification
Under penalties of perjury, I certify that the following information is correct.
TAXPAYER ID NUMBER: My correct Taxpayer Identification Number (TIN) is shown above.
BACKUP WITHHOLDING: I am not subject to backup withholding because either I have not been notified of being subject to backup withholding as a result of failure to report all interest or dividends, or the IRS has notified me that I am no longer subject to backup withholding.
EXEMPT RECIPIENTS: I am an exempt recipient under the Internal Revenue Service (IRS) Regulations.
NONRESIDENT ALIENS: I am not a citizen or a resident of the United States.
Under penalties of perjury, I /we certify that (1) the social security number(s), Taxpayer ID indicated above is/are my/our number(s)and (2) I/We am/are not subject to backup withholdings as a result of failure to report all interests or dividends, or the IRS has notified me that I am no longer subject to backup withholding.
Signature(s) -- The undersigned agree(s) to the terms stated in this form and acknowledge(s) receipt of a completed copy on today's date. The undersigned also acknowledge(s) receipt of a copy of and agree(s) to the terms of the following disclosure(s):
If the account(s) designated for this service are joint accounts, both account owners must sign this application.
Applicant Signature:
Date:
Co-Applicant Signature
Date:
You may transmit this application via the Internet, but you MUST print this application, sign it, and mail or deliver to the My Bank and Trust office nearest you.
