Personal Account Application
STEP 1 - PERSONAL INFORMATION
Choose an account type:
CNB Savings CNB Free Checking CNB 2000 Checking
CNB 2000 Gold CheckingTeacher's Appreciation
CNB Preferred Money Market

Name
 
Social Security Number
- - 		Date of Birth
(MM/DD/YYYY)
/ /

Home Phone
( ) - 		Mother's Maiden Name


Applicant's email:

Driver's License Number
or Registered ID
     State

Issued
(MM/DD/YYYY)
/ / 		Expires
(MM/DD/YYYY)
/ /
STEP 2 - ADDRESS INFORMATION
Residential Address ** (Required, not a P.O. Box)
City
 State
 Zip

Years There

Mailing Address (if different than above)

City
 State
 Zip

** If length of time at current address is less than two years, please complete the following:

Previous Address (Required, not a P.O. Box)

City
 State
 Zip

Years There
States Resided in Past 5 Years

Employer Name

Position

Work Phone and Extension
( ) -   

STEP 3 - JOINT ACCOUNT HOLDER INFORMATION (IF APPLICABLE)
Name (Co-Applicant)

Social Security Number
- - 		Birth Date
(MM/DD/YYYY)
/ /

Driver's License Number
or Registered ID
     State

Issued
(MM/DD/YYYY)
/ / 		Expires
(MM/DD/YYYY)
/ /

Address (if different than above)

City
 State
 Zip

Employer

Position

Work Phone and Extension
( ) -   

STEP 4 - INITIAL DEPOSIT AND SOURCE
Initial Deposit
$		 Source

STEP 5 - ATM or Debit Card Application
ATM Debit / Checking Card

COMMENTS

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 sign this application at the Citizens Nationa Bank branch office nearest you.

Citizens National Bank reserves the right to use the above information to obtain verifications of identity and background before opening any accounts. We may also access information about you from a consumer reporting agency, such as a copy of your credit report, before opening any account. By submitting this form, I/we grant full permission to do so.

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