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Deposit Account Application

DEPOSIT ACCOUNT APPLICATION


Select the type of account you wish to open

Checking
         Safe & Sound Checking:
         Allegiance Checking:
         Student Checking:

Savings
         Traditional Savings:
         Endurance Club Savings:
         Money Market:
         CD:
         IRA:


At which office location will you be doing most of your banking?

         Franceville:
         Monon:
         Monticello:
         Otterbein:
         Oxford:
         Rensselaer:
         Winamac:


Account Ownership

          Single Owner (individual):
          Joint (right to survivorship):
          Joint (no right to survivorship):
          In Trust For (ITF):


Primary Account Owner

*Name (First M. Last):
*Date of Birth (mm/dd/yy):
*Address:
*City, State, Zip:
*Primary Phone Number:
Work Phone Number:
*Drivers License
          Number:
          State:
          Issue Date (mm/dd/yy):
          Expiration Date (mm/dd/yy):
*Email Address:


Secondary Account Owner    (if you selected Joint account ownership)

Name (First M. Last):
Date of Birth (mm/dd/yy):
Drivers License
          Number:
          State:
          Issue Date:
          Expiration Date:


Beneficiary (if you selected ITF ownership)

Name (First M. Last):
Address:
City, State, Zip:
Primary Phone Number:


Deposit Information

*Initial Deposit Amount: $
*Initial Deposit Type:
Cash
Check
Wire Transfer


Taxpayer ID Number Certification

I am not subject to backup withholding either because I have not been notified that
I am subject to backup withholding as a result of a failure to report all interest or
dividends, or that Internal Revenue Service has notified me that I am
no longer subject to backup withholding.:
I am an exempt recipient under the Internal Revenue Service regulations.:
I am not a United States person, or if I am an individual, I am neither a citizen
nor a resident of the United States.:
I certify under penalties of perjury the statements checked in this section are true.:
I would like to access this account through Online Banking.:
I will provide 2 pieces of valid identification when coming in to sign my signature card.:

I certify that the information on this application and any attachments to be true and accurate. By signing below, I authorize Alliance Bank to conduct inquiries regarding my credit and employment histories, and to answer questions others may ask about my credit record with the Bank. I understand that I must update credit information at the Bank’s request if my financial condition changes. I authorize the Alliance Bank to keep this application regardless of its approval or denial of my account application.

*Signature:
*Date:


*Required Fields