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Personal Account Application

STEP 1 - PERSONAL INFORMATION

Account Type

Premier Checking

Premier Plus Checking

Positively Free Checking
Budget Checking

Regular Checking

NOW Checking Account
Money Market Bonus Account

Savings Account

Positively Free Student Checking

Name

Social Security Number
- - 		Date of Birth
(MM/DD/YYYY)
/ /

Home Phone
( ) - 		Mother's Maiden Name

Driver's License Number
or Registered ID
     State

Issued
(MM/DD/YYYY)
/ / 		Expires
(MM/DD/YYYY)
/ /

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STEP 2 - ADDRESS INFORMATION

Residential Address ** (Required, not a P.O. Box)
City
 State
 Zip

Years There

Mailing Address (if different than above)

City
 State
 Zip

** If length of time at current address is less than two years, please complete the following:

Previous Address (Required, not a P.O. Box)
City
 State
 Zip

Years There

States Resided in Past 5 Years


Employer Name

Position

Work Phone and Extension
( ) -   

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STEP 3 - JOINT ACCOUNT HOLDER INFORMATION (IF APPLICABLE)

Name (Co-Applicant)

Social Security Number
- - 		  Birth Date
(MM/DD/YYYY)
/ /

Driver's License Number
or Registered ID
     State

Issued
(MM/DD/YYYY)
/ / 		  Expires
(MM/DD/YYYY)
/ /

Address (if different than above)

City
 State
 Zip

Employer

Position

Work Phone and Extension
( ) -   

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STEP 4 - INITIAL DEPOSIT AND SOURCE

Initial Deposit
$ 		Source

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STEP 5 - ATM or Debit Card Application

ATM Debit Card

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COMMENTS

APPLICANT BACKUP WITHOLDING CERTIFICATION

Taxpayer ID Number: (If Taxpayer ID is same as your SSN, leave blank)

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Certification

Under penalties of perjury, I certify that the following information is correct.

 

TAXPAYER ID NUMBER: My correct Taxpayer Identification Number (TIN) is shown above.

 

BACKUP WITHHOLDING: I am not subject to backup withholding because either I have not been notified of being subject to backup withholding as a result of failure to report all interest or dividends, or the IRS has notified me that I am no longer subject to backup withholding.

 

EXEMPT RECIPIENTS: I am an exempt recipient under the Internal Revenue Service (IRS) Regulations.

 

NONRESIDENT ALIENS: I am not a citizen or a resident of the United States.

Under penalties of perjury, I /we certify that (1) the social security number(s), Taxpayer ID indicated above is/are my/our number(s)and (2) I/We am/are not subject to backup withholdings as a result of failure to report all interests or dividends, or the IRS has notified me that I am no longer subject to backup withholding.

Signature(s) -- The undersigned agree(s) to the terms stated in this form and acknowledge(s) receipt of a completed copy on today's date. The undersigned also acknowledge(s) receipt of a copy of and agree(s) to the terms of the following disclosure(s):

If the account(s) designated for this service are joint accounts, both account owners must sign this application

Applicant Signature:
 

Date:


Co-Applicant Signature

 

Date:

To open your account, we will need your signature and identification
to be provided at any one of our locations for the new account documentation.
Please drop by the location which is most convenient to you.

PointBank reserves the right to use the above information to obtain verifications of identity and background before opening any accounts. We may also access information about you from a consumer reporting agency, such as a copy of your credit report, before opening any account. By submitting this form, I/we grant full permission to do so.

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