Providence Bank - Personal Account Application

New Account Application

DATE:

*Account Ownership (ü)*	Fiduciary	Payable on Death Account	2.
Single Account	Living Trust	POD Beneficiaries:	3.
Joint Account	Minor Account	1.	4.

*Applying for (ü)*	Checking	Money Market	Individual Retirement Acct
*Applying for (ü)*	Savings	Certificate of Deposit	Health Savings Account (HSA)

<<<<<<<<<<<<<<< ACCOUNT HOLDER >>>>>>>>>>>>>>

First Name: MI: Last Name:

Social Security Number: - - Date of Birth: Home Phone: - -

Street Address: Mailing Address 2:

(Please note - P.O. Box holders must furnish physical address)

City: State: Zip Code: Mother's Maiden Name:

Driver’s License # (or other gov’t issued photo ID)** Issuing State:

Issued Date: Expiration Date:

Secondary Identification: Country of which you are a citizen:

Non Resident Alien (copy to Compliance) W-8 signed (copy to Compliance)

Employer: Work Phone: - -

Cell Phone ***: - - E-mail Address ***:

Challenge Questions are used to authenticate your identity and to facilitate the processing of transactions. Please choose one of the following questions and provide the correct answer.

1. In what city were you born?
2. Name of Elementary School?
3. What is your mother's maiden name?
4. What is your favorite color?
5. What is your pet's Name?
6. Who is your favorite artist?
7. What is your favorite movie?
8. What is your favorite hobby?
9. What is your favorite sports team?
10. Name of first employer?

*Please check all the services in this area that interest you:*
Check Card	Combined Statement	Direct Deposit	Automatic Payments (ACH)
Telephone Banking	Internet Banking	Email Statements	Banking Relationship
Overdraft Protection	Electronic Bill Pay	Automatic Transfers	Transfer Support

You authorize Providence Bank to make reference calls to verify your application information. All account applicants are verified through ChexSystems and Attus for Office of Foreign Assets Control Screening and for verification of identification information.

X________________________________________________

Signature – Account Holder I

**Identification Requirements: The USA Patriot Act requires the Bank to verify and retain a copy of each customer’s identification. All Account holders must provide the Bank with a copy of their driver’s license or other government issued photo identification.

*** Required for verification of account changes