Consumer Account Application

To help the government fight the funding of terrorism and money laundering activities, the USA Patriot Act 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 for your name, physical address, date of birth, and tax payer identification number (Social Security #) and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. We will let you know if additional information is required.

General

Type of Account

Are you signing individually or with a co-signer? Individually Joint

Primary Account Holder

First Name Middle Initial Last Name Social Security Number Birth Date Mother's Maiden Name Birth City Mobile Phone Number Work Phone Number E-mail Address Street Address City State Zip Code Mailing address is different than street address.

Mailing Address City State Zip Code

Occupation Employer Name Nearest Relative Not Living With You Relationship (of Relative) Phone Number (of Relative) Address (of Relative) City (of Relative) State (of Relative) Zip Code (of Relative)

Joint Account Holder

First Name Middle Initial Last Name Social Security Number Birth Date Mother's Maiden Name Birth City Mobile Phone Number Work Phone Number E-mail Address Street Address City State Zip Code Mailing address is different than street address.

Mailing Address City State Zip Code

Occupation Employer Name Nearest Relative Not Living With You Relationship (of Relative) Phone Number (of Relative) Address (of Relative) City (of Relative) State (of Relative) Zip Code (of Relative)

Additional

Payable on Death Agent/ Authorized Signer

If payable on death, enter beneficiary information

First Name Middle Initial Last Name Social Security Number Birth Date Mother's Maiden Name Birth City Mobile Phone Number E-mail Address Street Address City State Zip Code Mailing address is different than street address.

Mailing Address City State Zip Code

Occupation Employer Name Nearest Relative Not Living With You Relationship (of Relative) Phone Number (of Relative) Address (of Relative) City (of Relative) State (of Relative) Zip Code (of Relative)

If Agent/ Authorized Signer, enter their information

First Name Middle Initial Last Name Social Security Number Birth Date Mother's Maiden Name Birth City Mobile Phone Number E-mail Address Street Address City State Zip Code Mailing address is different than street address.

Mailing Address City State Zip Code

Occupation Employer Name Nearest Relative Not Living With You Relationship (of Relative) Phone Number (of Relative) Address (of Relative) City (of Relative) State (of Relative) Zip Code (of Relative)

Account Preferences

Debit/ATM Card Internet Banking Mobile Deposits Check blanks Bill Pay

What types of banking services do you expect to use at our financial institution on a monthly- basis? Fill out to the best of your ability. This is to help us get an idea of the type and amount of activity on your account.

Currency Deposits or Withdrawals

# per month Average $ Amount per month

Check Deposits

# per month Average $ Amount per month

U.S. Currency Exchanges

# per month Average $ Amount per month

International Currency Exchanges

# per month Average $ Amount per month

Domestice Wire Services

# per month Average $ Amount per month

International Wire Services

# per month Average $ Amount per month

ACH (Direct Deposit. Automatic Withdrawal) Transactions

# per month Average $ Amount per month

IAT (International) ACH Transactions

# per month Average $ Amount per month

Internet Banking Transfers

# per month Average $ Amount per month

Remote Deposit - Mobile Capture Services

# per month Average $ Amount per month

Purchase of Official Checks or Other Negotiable Items

# per month Average $ Amount per month

Safe Deposit Box

Access

Does the source of any of your funds come from a hemp related business(es) or product(s)? Yes No This includes but is not limited to: general retail sales of CDB Oil, Dispensary Sales of CBD oil, Pharmacy Sale of CBD oil, Online sales of CBD oil and Hemp producers of fibers, textiles, seed, meal, oil, imports or exports.

Please explain your involvement with hemp

Does the source of any of your funds come from a marijuana related business(es) or product(s)? Yes No This includes but is not limited to: adult or medical use, retail, processing, cultivation, testing, operations that support marijuana businesses, landlords of a marijuana business, etc.

Please explain your involvement with marijuana

Please describe any other services or activities not listed here that you wish to use at our financial institution

Signature Card

We will contact you upon receiving your application to schedule a time that is convenient to finish account opening procedures.

Which branch would you like to come into and sign signature cards?

Location

Additional Requests

I am aware that I will be required to provide a copy of my Photo ID and social security card before account opening.

I have additional questions or requests Yes No

Please explain

Endorsement

By submitting this application, I certify that I gave truthfully and fully provided the information required and that I am at least 18 years of age and live in the U.S.

By signing below, I authorize you to check my credit account and employment history and/or have a credit reporting agency prepare a credit report on me. I also authorize you to take steps to verify my indentity.

The purpose of this questionnaire is to begin the application process. All applications are subject to approval.

By entering my name below, I hereby give the electronic equivalent of my signature.

Primary Account Holder's Signature Date Co-Applicant's Signature Date

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