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New Deposit Account Application

Important Information About Procedures For Opening A New Account :

PATRIOT ACT
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

What this means for you: When you open an account, we will ask you for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

* Required Fields

Please choose the type of account you are applying for:

Primary Account Holder Information

*First Name:
Middle Initial:
*Last Name:
*Social Security Number:
*Drivers License Number
*State Issued
*Date of Issuance:
*Date of Expiration:
*Home Phone:
Work Phone:   Ext:
*Date of Birth:
Occupation:
*Employer:
*Mother's Maiden Name:

Joint Account Holder Information (if applicable)

Check here if there is a joint applicant
First Name:
Middle Initial:
Last Name:
Social Security Number:
Drivers License Number
State Issued
Date of Issuance:
Date of Expiration
Home Phone:
Work Phone:   Ext:
Date of Birth:
Occupation:
Employer:
Mother's Maiden Name:
   

Address Information

*Street Address:
*City:
*State:
*Zip: -
E-Mail Address:
 
Mailing address if different from above:
Mailing Address:
City:
State:
Zip: -

Account Ownership

Ownership
Single Owner (individual)
Joint (with right to survivorship)
Joint (with no right to survivorship)

Beneficiaries

If Payable on Death, Name and Address of Beneficiary ...
Name (First, Middle, Last):
Street Address:
City:
State:
Zip: -
Relationship:
   
If Payable on Death, Name and Address of Second Beneficiary (if applicable) ...
Name (First, Middle, Last):
Street Address:
City:
State:
Zip: -
Relationship:

Account Preferences

  MasterCard Check Card/ATM Card
  E-Statements
  Direct Deposit
  Full Time Student
  Would you like an application for Overdraft Protection?

Taxpayer Identification

As a condition of acceptance of my deposit application, I authorize you to obtain a copy of my current credit report and subsequent reports for the purpose of an update, renewal or extension of credit.
I am not subject to backup withholding, because I am exempt from backup withholding, or because I have not been notified by the IRS that I am subject to backup withholding as a result of failure to report all interest or dividends, or because the IRS has notified me that I am no longer subject to backup withholding.
I am subject to backup withholding.
I am not a United States citizen or resident.
I certify under penalties of perjury that the statements contained in this section are correct.
  By submitting this application, I certify that I/we gave truthfully and fully provided the information required and that I am at least 18 years of age and live in the US. I certify that I have read and agreed to all the Terms & Conditions, Disclosures and Privacy Policy. I agree that I may receive electronic communications posted on the Coffee County Bank Web Site or delivered to the e-mail address I provide, including information required by various laws and regulations. I authorize Coffee County Bank to access my credit bureau information, check my employment, and report to credit reporting agencies Coffee County Bank experience with me.
   
I will come in and sign my Signature Card and make my required deposit for the account selected. We will contact you upon account approval to schedule a time that is convenient.