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Single Owner (Individual) |
Joint (with rights of survivorship) |
| Choose Type of Account: |
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| Certificate
of Deposit Term: |
for deposits up to $100,000 |
| Jumbo Term: |
for deposits over $100,000 |
|
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| First Name: |
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| Middle Initial: |
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| Last Name: |
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| Date of
Birth: |
(mm/dd/yyyy) |
| Place of
Birth: |
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| Taxpayer
ID# (SSN): |
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| Home Address: |
(Cannot be a P.O. Box) |
| City, State,
Zip: |
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| Length of
Time (Home): |
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| If less than 1 year, previous address |
(Cannot be a P.O. Box) |
| Previous City, State,
Zip: |
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| Home Phone: |
(000-000-0000) |
| Work Phone: |
(000-000-0000) |
| Cell Phone: |
(000-000-0000) |
| Email: |
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| Mother's Maiden Name: |
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| Employer: |
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| Employer
Address: |
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| City, State,
Zip: |
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| Length of
Time (Work): |
|
|
 |
 signer
#1 |
| Massachusetts Residents
Only: |
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| Non-Massachusetts Residents: |
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| State: |
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| Country: |
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| Number: |
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| Expiration
Date: |
|
| Issue Date: |
|
 signer
#1 |
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| State: |
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| Country: |
|
| Number: |
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| Expiration Date: |
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| Issue Date: |
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|
 |
| First Name: |
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| Middle Initial: |
|
| Last Name: |
|
| Date of
Birth: |
(mm/dd/yyyy) |
| Place of
Birth: |
|
| Taxpayer
ID# (SSN): |
|
| Home Address: |
(Cannot be a P.O. Box) |
| City, State,
Zip: |
|
| Length of
Time (Home): |
|
| If less than 1 year, previous address |
(Cannot be a P.O. Box) |
| Previous City, State,
Zip: |
|
| Home Phone: |
(000-000-0000) |
| Work Phone: |
(000-000-0000) |
| Cell Phone: |
(000-000-0000) |
| Email: |
|
| Mother's Maiden Name: |
|
| Employer: |
|
| Employer
Address: |
|
| City, State,
Zip: |
|
| Length of Time (Work): |
|
|
 |
|
| signer
#2 |
| Massachusetts Residents
Only: |
|
| Non-Massachusetts Residents: |
|
| State: |
|
| Country: |
|
| Number: |
|
| Expiration Date: |
|
| Issue Date: |
|
signer
#2 |
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| State: |
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| Country: |
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| Number: |
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| Expiration Date: |
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| Issue Date: |
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| |
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| Direct Deposit into Account
No
Yes |
| If Yes, Name of Company or
Source |
Check here for initial order of printed checks (for
Checking & Money Market Accounts Only) |
ATM/Debit Card |
|
Wainwright Bank ATM/Debit Card (Issuance
requires $10 balance) |
| (Savings accounts without
an associated checking account will receive an ATM card.) |
|
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| Initial Deposit Amount: |
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| Initial Deposit Type: |
|
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| Transfer
from an Existing Wainwright Bank Account (please
select the type) |
| Transfer Type: |
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| Transfer Account Number: |
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If initial deposit is to be made by credit card, I authorize Wainwright Bank & Trust Company upon receipt of my completed, signed Signature Card and required documentation, to submit a charge against the credit card number to be provided at that time for the opening deposit amount listed. This amount is not to exceed $1,000. |
Backup Withholding Certification
By checking this box, I certify, under
penalties of perjury, that ALL of the following conditions are true.
If you have been notified by the IRS that you are subject to backup
withholding, please leave this box blank. I understand that if
I leave the box blank, I will be subject to backup withholding:
1. The number shown on this form is my correct taxpayer identification
number (social security number) or I am waiting for a number to
be issued to me.
2. I am not subject to backup withholding because: (a) I am exempt
from backup withholding, 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 IRS has notified me that I am no longer subject to backup
withholding.
3. I am a U.S. person (including a U.S. resident alien). |
|
I/We authorize Wainwright
Bank & Trust Company to obtain any appropriate credit information
including, but not limited to, information from Efunds/ChexSystems as a condition of acceptance of this application
and for the purpose of extension of or renewal of credit.
Federal law requires us to obtain sufficient information to verify
your identity. You may be asked several questions and to provide
one or more forms of identification to fulfill this requirement.
In some instances we may use outside sources to confirm the information.
The information you provide is protected by our privacy policy and federal law.
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