form test


Type of Account

Individual

Joint

Primary Account Owner

First Name

MI

Last Name

Mailing Address

City

State

ZIP

Physical Address

City

State

ZIP


Phone





E-mail Address

Date of Birth



SSN




Joint Account Owner (if desired)

First Name

MI

Last Name

Mailing Address

City

State

ZIP

Physical Address

City

State

ZIP


Phone





E-mail Address

Date of Birth



SSN





Do you currently have a checking account?

Yes

No

Are you a full-time student?

Yes

No

How many checks do you write each month?

Which type of account access do you prefer?

Check Card

Paper Checks

Internet Bill Pay

Please estimate the average checking balance you will maintain.

Which of the following benefits are important to you?



Free Printed Checks


Extra Benefits (no-fee traveler’s checks, small safe deposit box)


Check Safekeeping


Images returned with monthly statements


No minimum balance


No monthly service charge


E-mail Statements


None

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.

Primary Owner’s Driver’s License
#

Issuing State

Issue Date



Expiration Date



Joint Owner’s Driver’s License #

Issuing State

Issue Date



Expiration Date



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.


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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