Personal Checking Application

Type of Account

Cash Back Banking

Advantage Club Checking

Heritage Checking

Premier Club Checking

Student Checking

Individual or Joint Account

Individual

Joint

Primary Account Owner

Name*

First Last

Physical Address*

Street Address Address Line 2 City State ZIP Code

Would you like to add a different mailing address?

Yes

Mailing Address

Street Address Address Line 2 City State ZIP Code

Phone*

Date of Birth

Social Security Number*

Do you currently have a checking account?

Yes

Are you a full-time student?

Yes

About how many debit card purchases do you make each month?*

How many checks do you write each month?

Please estimate the average checking balance you will maintain.

Which type of account access do you prefer?

Debit Card

Paper Checks

Internet Bill Pay

Which of the following benefits are important to you?

Free Printed Checks

Free small safe deposit box

Bill Pay

Images returned with monthly statements

No minimum balance

No monthly service charge

E-mail Statements

None

Joint Account Owner (if desired)

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth

Social Security Number*

Disclosures & Acknowledgements

USA Patriot Act Disclosure

On September 11, 2001 our lives changed forever. In an effort to protect you and our country, the USA Patriot Act was signed into law. To help the government fight the funding or 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.

You are applying for a deposit account. We therefore asked you for your name, address, date of birth and other information that will allow us to identify you. If you are not currently a Heritage Bank customer, we must also ask you to complete the driver’s license or other identifying information below.

Primary Owner's Driver’s License #*

Issuing State*

Issue Date*

Expiration Date*

Joint Owner's Driver’s License #*

Issuing State*

Issue Date*

Expiration Date*

Certification & Authorization
I/we understand that a bank employee will contact me to discuss product options and set up a time when I/we can come to the bank to finish opening the account (sign the account agreement and receive all of the necessary disclosures related to the product I/we choose). I/we understand that I/we will be the only individual(s) authorized to use this account. I/we authorize the bank to make inquiries to the credit bureau, and verify all information on this application. I/we acknowledge that all Heritage Bank locations are in fact part of one bank and that the deposits held at each office are not separately insured.

Certification & Authorization*

I have read the disclosures and acknowledgements above and agree to the terms and conditions that are stated within them by Heritage Bank.

Phone

This field is for validation purposes and should be left unchanged.

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