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Business Deposit Account Application

Note: Once your application has been received one of our Customer Service

Representative will be contacting you to schedule an appointment at the bank in order

to complete the account opening process.

*Indicates a Required Field

Leave me blank for Business Deposit Account App.

Account Desired: *

Hometown Business Checking Hometown Premiere Business Checking Statement Savings Corporation For-Profit Nonprofit Sole Proprietorship Limited Liability Company/LLP Partnership (written agreement) Lodge/Association

Business Applicant

Business Name *

Tax ID/EIN or Taxpayer # (Sole prop some LLCs) *

Business Type/Nature of Business * Physical Address of Business *

Business Physical Address City *

Business Physical Address State *

Business Physical Address Zip *

Mailing Address of Business (if different from physical address)

Business Mailing Address City

Business Mailing Address State

Business Mailing Address Zip

Business Phone (xxx-xxx-xxxx) *

Business Email Address *

Certification of Beneficial Owner(s) and controlling Person of Legal Entity (Certification)

Legal name of Business Entity *

Name of person opening account *

The following information for each entity who, directly or indirectly, through any contract, arrangement, understanding, relationship or otherwise, owns 25% or more of the equity interests of the above listed business. If no individual meets this definition, check this box.

Equity Owner 1

Owner 1 Title

Owner 1 Percent of Ownership

Owner 1 Full Name

Owner 1 Date of Birth (mmddyyyy)

Owner 1 Last 4 digits of SSN

Owner 1 Are you a US Citizen?

Yes No

Owner 1 Home Phone (xxx-xxx-xxxx)

Owner 1 Cell Phone (xxx-xxx-xxxx)

Owner 1 Email Address

Owner 1 Physical Address

Owner 1 Physical Address City

Owner 1 Physical Address State

Owner 1 Physical Address Zip

Owner 1 ID Type

Owner 1 ID Number

Owner 1 Expiration Date

Equity Owner 2

Owner 2 Title

Owner 2 Percent of Ownership

Owner 2 Full Name

Owner 2 Date of Birth (mmddyyyy)

Owner 2 Last 4 digits of SSN

Owner 2 Are you a US Citizen?

Yes No

Owner 2 Home Phone (xxx-xxx-xxxx)

Owner 2 Cell Phone (xxx-xxx-xxxx)

Owner 2 Email Address

Owner 2 Physical Address

Owner 2 Physical Address City

Owner 2 Physical Address State

Owner 2 Physical Address Zip

Owner 2 ID Type

Owner 2 ID Number

Owner 2 Expiration Date

Equity Owner 3

Owner 3 Title

Owner 3 Percent of Ownership

Owner 3 Full Name

Owner 3 Date of Birth (mmddyyyy)

Owner 3 Last 4 digits of SSN

Owner 3 Are you a US Citizen?

Yes No

Owner 3 Home Phone (xxx-xxx-xxxx)

Owner 3 Cell Phone (xxx-xxx-xxxx)

Owner 3 Email Address

Owner 3 Physical Address

Owner 3 Physical Address City

Owner 3 Physical Address State

Owner 3 Physical Address Zip

Owner 3 ID Type

Owner 3 ID Number

Owner 3 Expiration Date

Complete the following information for an individual with significant responsibility for managing the above listed business, i.e., Executive officer (CEO, CFO, and COO, Managing Member, General Partner, President, Vice President or Treasurer), OR any other individual who regularly performs similar functions.

Significant Individual Title

Significant Individual Percent of Ownership

Significant Individual Full Name

Significant Individual Date of Birth (mmddyyyy)

Significant Individual Last 4 digits of SSN

Significant Individual Are you a US Citizen?

Yes No

Significant Individual Home Phone (xxx-xxx-xxxx)

Significant Individual Cell Phone (xxx-xxx-xxxx)

Significant Individual Email Address

Significant Individual Physical Address

Significant Individual Physical Address City

Significant Individual Physical Address State

Significant Individual Physical Address Zip

Significant Individual ID Type

Significant Individual ID Number

Significant Individual Expiration Date

Authorized Signers

Authorized Signer 1

Authorized Signer 1 Title

Authorized Signer 1 Percent of Ownership

Authorized Signer 1 Full Name

Authorized Signer 1 Date of Birth (mmddyyyy)

Authorized Signer 1 Last 4 digits of SSN

Authorized Signer 1 Are you a US Citizen?

Yes No

Authorized Signer 1 Home Phone (xxx-xxx-xxxx)

Authorized Signer 1 Cell Phone (xxx-xxx-xxxx)

Authorized Signer 1 Email Address

Authorized Signer 1 Physical Address

Authorized Signer 1 Physical Address City

Authorized Signer 1 Physical Address State

Authorized Signer 1 Physical Address Zip

Authorized Signer 1 ID Type

Authorized Signer 1 ID Number

Authorized Signer 1 Expiration Date

Authorized Signer 2

Authorized Signer 2 Title

Authorized Signer 2 Percent of Ownership

Authorized Signer 2 Full Name

Authorized Signer 2 Date of Birth (mmddyyyy)

Authorized Signer 2 Last 4 digits of SSN

Authorized Signer 2 Are you a US Citizen?

Yes No

Authorized Signer 2 Home Phone (xxx-xxx-xxxx)

Authorized Signer 2 Cell Phone (xxx-xxx-xxxx)

Authorized Signer 2 Email Address

Authorized Signer 2 Physical Address

Authorized Signer 2 Physical Address City

Authorized Signer 2 Physical Address State

Authorized Signer 2 Physical Address Zip

Authorized Signer 2 ID Type

Authorized Signer 2 ID Number

Authorized Signer 2 Expiration Date

Authorized Signer 3

Authorized Signer 3 Title

Authorized Signer 3 Percent of Ownership

Authorized Signer 3 Full Name

Authorized Signer 3 Date of Birth (mmddyyyy)

Authorized Signer 3 Last 4 digits of SSN

Authorized Signer 3 Are you a US Citizen?

Yes No

Authorized Signer 3 Home Phone (xxx-xxx-xxxx)

Authorized Signer 3 Cell Phone (xxx-xxx-xxxx)

Authorized Signer 3 Email Address

Authorized Signer 3 Physical Address

Authorized Signer 3 Physical Address City

Authorized Signer 3 Physical Address State

Authorized Signer 3 Physical Address Zip

Authorized Signer 3 ID Type

Authorized Signer 3 ID Number

Authorized Signer 3 Expiration Date

Business Account Due Diligence

Opening Deposit *

Source of Funds *

Cash Check Internal Transfer

If internal transfer, please give account number.

Do you/Will you cash checks for people? *

Yes No

If yes, what is the maximum amount of checks that can be cashed for any one person in one day?

What type of checks are cashed? Personal Payroll Other (Please specify below)

Specify Other

Do you/Will you sell cashier's checks or money orders? *

Yes No

If yes, what is the maximum amount of money orders/cashier's checks that can be sold to one person in a day? What agent provides your money orders/cashier's checks?

Do you/Will you perform money wire transfers? *

Yes No

Are you an agent for a money transfer service? *

Yes No

If yes, who?

Do you/Will you sell prepaid stored value cards? *

Yes No

If yes, what is the maximum amount of prepaid stored value cards that can be sold to one person in one day?

Do you/Will you perform currency exchanges? *

Yes No

If yes, what is the maximum amount of currency exchange that can be done for one person in one day?

Internet Gambling *

This business IS NOT engaged in Internet gambling. In the event the business does engage in legal internet gambling, it will notify the bank and provide proof that the gambling activity is legal. This business IS engaged in legal Internet gambling and will provide any proof required by the bank that the gambling activity is legal. We will also comply with any bank request for ongoing certification that the internet gambling in is engaged.

I, the Person completing this form, hereby certify, to the best of my knowledge, that the information provided herein is complete and correct. I also agree to notify Citizens National Bank of any change in the information provided within this Certification. Full Name of Person Completing This Form *

There was an error submitting the form

Your form was submitted successfully! We will be in touch soon.

Routing#: 091202325 | Phone: 218-732-3393

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