Lamar National Bank | Deposit Account Application

Checking & Savings 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:
* Email Address:

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:
Home Phone:
Work Phone:	Ext:
Date of Birth:
Occupation:
Employer:
Mother's Maiden Name:
Email Address:
Would you like to add another account owner?

First Name:
Middle Initial:
Last Name:
Social Security Number:
Drivers License Number:
State Issued:
Home Phone:
Work Phone:	Ext:
Date of Birth:
Occupation:
Employer:
Mother's Maiden Name:
Email Address:
Would you like to add another account owner?

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

Address Information

* Street Address:

* City:

* State:

* Zip:

-

Mailing address if different from above:

Mailing Address:

City:

State:

Zip:

-

Ownership

	Single Party, payable on death
	Single Party, not payable on death
	Multi-Party with right of survivorship
	Multi-party without right of survivorship
	Multi-Party with right of survivorship and 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:

Percentage:

Would you like to add another beneficiary?

Name (First, Middle, Last):
Street Address:
City:
State:
Zip:	-
Social Security Number:
Relationship:
Percentage:
Would you like to add another beneficiary?

Name (First, Middle, Last):
Street Address:
City:
State:
Zip:	-
Social Security Number:
Relationship:
Percentage:


Opening Deposit
* Deposit Amount:
* Deposit Type:

Account Preferences

	MasterCard/Debit Card
	Online Banking
	Savings Account
	Order Checks
	Overdraft Protection

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

	I agree to come in and sign my Signature Card and make my deposit.
	We will contact you upon account approval to schedule a time that is convenient.