DEPOSIT ACCOUNT APPLICATION
Select the type of account you wish to open
Checking
Safe & Sound Checking:
Allegiance Checking:
Green Checking:
Savings
Traditional Savings:
Endurance Club Savings:
Money Market:
CD:
IRA:
At which office location will you be doing most of your banking?
Francesville:
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