New Account Application

Important Information About Procedures for Opening a New Account:

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 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.

* Indicates Required Information

ACCOUNT HOLDER INFORMATION PRIMARY OWNER JOINT OWNER
Name*
Business Name
D.O.B.* (MM/DD/YY) (MM/DD/YY)
SSN*
P.O. Box
Street Address
City*
State*
ZIP*
Driver's License Number*
Driver's License State*
Employer*
Home Phone* (000-000-0000) (000-000-0000)
Work Phone* (000-000-0000) (000-000-0000)
Email Address

OWNERSHIP OF ACCOUNT
Personal Accounts Single with payable on death Single without payable on death Multiple with right of survivorship
Multiple without right of survivorship Multiple with right of survivorship & payable on death  
List Beneficiaries
Commercial Accounts Sole Proprietorship Corporation Profit Corporation Non-Profit
Unincorporated Association Other Partnership

ACCOUNT INFORMATION
Initial Deposit
Previous Bank
Check Options
Include Driver's License on Checks   Include home phone number on checks

CHECK ONE OR MORE OF THE ACCOUNTS BELOW TO APPLY FOR:

Regular Checking Senior Citizen Checking Student Checking NOW Checking
Money Markey Checking Statement Savings Money Market Savings Certificate of Deposit
IRA Business Checking Business Statement Savings    

CHECK ONE OR MORE OF THE SERVICES BELOW TO APPLY FOR:

ATM Card Debit Card Credit Card Safe Deposit Box Internet Banking

Certification

I certify that I am at least 18 years of age and I have accurately and fully completed all items on this application. Under penalties of perjury, I certify that:

  1. The social security number (SSN) and/or tax payer identification number (TIN) shown above is my correct number;
  2. I am NOT subject to backup withholding because (a) I am exempt from backup witholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the Internal Revenue Service has notified me that I am no longer subject to backup withholding; and
  3. I am a U.S. person (including a U.S. resident alien). 

Or check all that apply:

  I have been notified that I am subject to backup withholding.

  I am not a U.S. citizen or resident (complete W-8) form.

The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

Please note, this application is subject to verification and approval. In order for us to process your application correctly, we may need to contact you to verify some of the information or request additional documentation. When you submit this application, you certify that everything stated above is true and accurate.  When you submit this application, you also agree that this Institution reserves the right to review your credit history through an authorized bureau.

If you have any questions, please contact us at 701-782-6295, or by e-mail at customerservice@bankofhazelton.net.

By clicking below, I hereby certify that everything I have stated above is correct. You may keep this application whether or not it is approved. By clicking below, I authorize you to check my credit and employment history and verify other information which I have provided to you.