COD 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 Field

Please select your preferred
Citizens National Bank office

Please choose the type of account
you are applying for:

	91 Days
	182 Days
	7 Months
	12 Months
	18 Months
	24 Months
	30 Months
	36 Months
	60 Months

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:		-

Ownership

	Single Owner (individual)
	Joint (with right to survivorship)
	Joint (with no right to survivorship)
	Payable on Death


If Payable on Death, Name and Address of Relation
Name (First, Middle, Last):	*
Street Address:	*
City:	*
State:	*
Zip:	*	-
Social Security Number:	*
Relationship:	*

Power of Attorney (if applicable)
		Check here if there is a Power of Attorney

Name (First, Middle, Last):	*
Street Address:	*
City:	*
State:	*
Zip:	*	-
Social Security Number:	*
Date of Birth:	*

Opening Deposit

Deposit Amount:

Deposit Type:

Interest Payment Method

Compounded
(Added to the CD balance monthly)

Credit to another CNB account

Account Number

Credit to a checking or savings account at another institution

Bank Name
Routing Number
Account Number
Account Type

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 Privacy Policy. I agree that I may receive electronic communications posted on the Citizens National Bank web site or delivered to the e-mail address I provide, including information required by various laws and regulations. I authorize Citizens National Bank to access my credit bureau information, check my employment, and report to credit reporting agencies Citizens National Bank's experience with me.

COD Account Application

Important Information About Procedures For Opening A New Account

(PATRIOT ACT)

Primary Account Holder Information

Joint Account Holder Information (if applicable)

Address Information

Ownership

Power of Attorney (if applicable)

Opening Deposit

Taxpayer Identification