Deposit Account Application



	Arkansas City / Douglass / Lawrence / Oxford / Wellington / Wichita / Winfield

Deposit Account Application
Please note: The primary applicant must be a U.S. Citizen to qualify for this Internet offer.

Account Type:

Cornerstone Checking
Cornerstone Checking Plus

Freedom Checking
Freedom Money Market

Prime Time I
Prime Time II
Prime Time III

Please enter the following information about yourself:

Legal Name (First Middle Last):

Date of Birth(MM/DD/YYYY):

Address:

City, State:

ZIP-Plus4:

Email Address:

Driver's License State / License #:

Driver's License Expiration Date:

Occupation:

Employer:

Please select the type of ownership for the account:
Individual
Joint

Pay-on-death account with the following Beneficiary Information:

	Legal Name (First Middle Last):
	Address:
	City, State:		,
	ZIP-Plus4:

	If this is to be a joint account, complete the following:
	Joint Legal Name (First Middle Last):
	Date of Birth (MM/DD/YYYY):
	Joint Address:
	City, State:				,
	ZIP-Plus4:
	Email Address:
	Driver's License State / Number:
	Driver's License Expiration Date:
	Occupation:
	Employer:

	Primary Applicant's Contact Information:
	Home Phone #: 123.123.1234 format
	Business Phone #:
	Primary Applicant's Mother's Maiden Name:


	Deposit Information:
	Initial Deposit:	$ (No commas (,) or dollar signs ($), please.)
	Deposit Type:

Fill out the following information only if depositing via a credit card.
	Card Type:
	Card No.:
	Name (First Middle Last):
	Card Valid Through:

	Account Owner's SSN:	Joint Owner's SSN:
	Social Security Number(s): The Social Security Number shown above is my correct Social Security number. Backup Withholding: I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of failure to report all interest of dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding Exempt Recipients: I am an exempt recipient under the Internal Revenue Service Regulations. Nonresident Aliens: I am not a United States person, or if I am an individual, I am neither a citizen nor a resident of the United States. As a condition of acceptance of my checking account with CornerBank, N.A.® , I authorize you (CornerBank, N.A.® ) to obtain a copy of my current credit report and subsequent reports for the purpose of an update, renewal or extension of credit, or opening of deposit accounts. I certify under penalties of perjury the statements checked in this section are true.

	Additional Products/Services I wish to apply for the following additional products/services: Overdraft Protection ATM Card VISA Checkcard Bankline Telephone Transfer Access

	I agree to the terms stated on the above pages of this form and acknowledge receipt of a completed copy on today's date. I also acknowledge the terms of the following disclosures: Privacy Notice Electronic Funds Transfer Agreement and Disclosures Funds Availability Policy Disclosure Truth In Savings Disclosure Deposit Account Agreement and Disclosure Miscellaneous Fees and Charges U.S.A. Patriot Act Customer Identification Program These disclosures contain information that is pertinent to how we service your banking needs on a daily basis, such as direct deposits, "stop payment" instructions, personal information privacy and more. You are encouraged to either print them out for your personal files or save them as a HTML document to your hard drive.



	Important Steps to Finalize Your Application Thank you for applying for a CornerBank checking account. We will process your application once you have completed these important final steps: Application Form A. Please verify that all the information has been entered correctly. B. You must print this form and return the original signed form to us. Print this form by choosing your browser's print option. IF YOU CANNOT PRINT WEB DOCUMENTS, CHECK HERE If you are unable to print the application, please e-mail Internet Banking Support at support@cornerbanks.com indicating you have submitted a deposit application and are unable to print. We will mail you a copy of your application for your signature. We cannot process your request until we have the signed application returned to us, along with the supporting documents. C. Submit your application by pressing the "Submit" button below. D. Sign and date the application in the space provided. The application must be signed by all owners of the account. E. Mail the signed, dated application, along with copies of the requested documents (see "Forms of Identification") to: CornerBank, N.A. Attn: Internet Banking Support 900 Main, PO. Box 545 Winfield, KS 67156 Forms of Identification -* You will also need to send us photocopies of two forms of identification for each joint owner, including one photo ID (e.i. driver's license), plus a copy of your Social Security card(s). Deposit - Depending upon the deposit method you selected above, please do one the following: Check / Money Order Enclose the initial deposit check with the copy of this form and your forms of identification. Credit Card We will charge your credit card for the amount of your initial deposit as indicated on your application. Wire If you choose to make your initial deposit by wire, please first fax this form to us. Fax: (620) 221-0867 The ABA number for the wire is 101101109 for CornerBank, N.A., ATTN: Internet Banking Dept. Your account cannot be opened until we receive the deposit. We will confirm your application by e-mail within 5 working days after receipt of your signed application. After reviewing your application, additional documents may be requested to continue processing. Upon approval of your application, we will forward to you a new account packet containing information about your new account and other bank services.

Signatures:

Applicant Signature:________________________ Date:______________

Joint Owner Signature:______________________ Date:______________

Call us at:
620-221-1650 or 800-408-9273
Bankline:
620-221-0974 or 800-408-9324

Member FDIC Equal Housing Lender

Important Steps to Finalize Your Application

Signatures: