Business Deposit Account Application

(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.

Business Information

Business Name Tax ID Number Business Phone Number Business Fax Number

Business Type Sole Proprietor Corporation Partnership LLC Non-Profit Other

Business Type Street Address City State Zip Code Mailing address is different than street address.

Mailing Address City State Zip Code

Signer Information

First Name Middle Initial Last Name Suffix Social Security Number Birth Date Mailing Address City State Zip Code Daytime Phone Number Home Phone Number E-mail Address

How would you prefer to be contacted? Home Phone Work Phone Email Other

Other Preference Form of Photo Identification Issued By ID Number Issue Date Expiration Date

Are you applying as an individual or with another authorized signer? Individual With another authorized signer

Other Authorized Signer Information

First Name Middle Initial Last Name Suffix Social Security Number Birth Date Mailing Address City State Zip Code Daytime Phone Number Home Phone Number E-mail Address

How would you prefer to be contacted? Home Phone Work Phone Email Other

Other Preference Form of Photo Identification Issued By ID Number Issue Date Expiration Date

Products and Services Needed

Accounts

Select additional account services needed.

Small Business Checking Business Checking with Interest Business Analysis Checking

Business Savings Business Money Market High Yield Money Market Certificate of Deposit

CD Term

Additional Services

Select additional services needed.

Visa Debit Card Account Number Checking Account Number

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

Certification

I certify that all information provided by me herein, including attachment(s) is true, correct and complete. Upon receiving this information, United Republic Bank will reach out to you to complete the Account Opening Process. I then agree to provide any further information the Bank might require to process my application.

Applicant's Signature Date

Other Authorized Signer's signature Date

Type the numbers you see above: