Agricultural Checking Application

*Must be at least 19 years of age to apply for a loan or deposit account alone

BUSINESS INFORMATION

Business Name

Owner's Name*

FirstLast

Address*

Street AddressAddress Line 2CityStateZip Code

Phone*

Email*

Date of Birth*

MM

DD

YYYY

Social Security Number*

Type of Organization*

Do you currently have a checking account?*

Yes
No

How many checks do you write each month?*

How often will you make business deposits?*

Which of the following benefits are important to you?*

Authorized Signers:

Name (Authorized Signer 1)

FirstLast

Date of Birth

MM

DD

YYYY

Social Security Number

Name (Authorized Signer 2)

FirstLast

Date of Birth

MM

DD

YYYY

Social Security Number

Disclosures & Acknowledgements

USA Patriot Act Disclosure

On September 11, 2001 our lives changed forever. In an effort to protect you and our country, the USA Patriot Act was signed into law. To help the government fight the funding or 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.

You are applying for a deposit account. We therefore asked you for your name, address, date of birth and other information that will allow us to identify you. If you are not currently a Heritage Bank customer, we must also ask you to complete the driver’s license or other identifying information below.

Certification & Authorization
I/we understand that a Personal Banker will contact me to discuss product options and set up a time when I/we can come to the bank to finish opening the account (sign the account agreement and receive all of the necessary disclosures related to the product we choose). I/we understand that I/we will be the only individual(s) authorized to use this account. I/we authorize the bank to make inquiries to the credit bureau, and verify all information on this application. I/we acknowledge that all Heritage Bank locations are in fact part of one bank and that the deposits held at each office are not separately insured.

Certification & Authorization*

I have read the disclosures and acknowledgements above and agree to the terms and conditions that are stated within them by Heritage Bank.

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Agricultural Checking Application