Account Owner Authorized Signer
Name: ______________________________, _______________________ ________
(Last) (First) (M.I.)
Street Address*: ____________________________________________________
*(P.O. Box holders must also document physical address)
City: ________________________ State: ________________ Zip + 4: ___________-________
Social Security: ______-____-______ Date of Birth: ___________ Password: _______________
Home Phone: _________________ Work Phone: ________________ Fax: _________________
Cellular Phone:___________________ E-mail (optional): _______________________________
Approved Photo ID: Driver’s License; State ID; Other (Specify) __________________
No.: _______________ Issuing State__________ Exp. Date: __________
Federal regulations require depository institutions to retain documentation of customer identification verification. A photocopy of photo identification must be attached to this form.
Account Description: ________________; __________________________________________
(Transaction/ Time and Ownership: Individual, Joint, Legal Entity, etc.)
Interest rate: ______% Annual Percentage Yield: _______% Term (if applicable): ___________
Initial Deposit Amount: $___________________ or Current Balance $_____________________
Source of Funds: Cash; Check; Internal Transfer (Account No.______________)
Comments/Special Instructions:
The information that I have provided above is correct to the best of my knowledge and I hereby authorize ___(Name of Financial Institution)___ to check credit and/or employment history.
Account Information Verification is provided by:_____________________________________. _________________________________________ Date: _____________,______
(Signature of account owner or authorized signer)
Bank Notation: Office/Branch: __________________ Employee: ____________________