Riverland Bank - Jordan MN
Consumer Deposit Application

            2/4/2010  
SECTION A - INDIVIDUAL APPLICANT INFORMATION
NAME
FIRST MIDDLE LAST SSN/EIN
       

 

BIRTH DATE HOME PHONE CELL PHONE BUSINESS PHONE
                   

 

ADDRESS
STREET CITY   STATE ZIP CODE
       

 

HOW LONG AT THIS ADDRESS   LIVE IN MN LAST 5 YRS 
DRIVERS LICENSE EXPIRATION DATE ISSUE DATE E-MAIL  ADDRESS
       

 

CURRENT EMPLOYER   POSITION HOW LONG EMPLOYED
     

             YRS               MONTHS

DEPOSIT AMOUNT DEPOSIT SOURCE
      $  
SECTION B - JOINT APPLICANT INFORMATION
NAME
FIRST MIDDLE LAST SSN/EIN
       

 

BIRTH DATE HOME PHONE CELL PHONE BUSINESS PHONE
                   

 

ADDRESS
STREET CITY   STATE ZIP CODE
       

 

HOW LONG AT THIS ADDRESS   LIVE IN MN LAST 5 YRS 
DRIVERS LICENSE EXPIRATION DATE ISSUE DATE E-MAIL  ADDRESS
       

 

CUSTOMER IDENTIFICATION PROGRAM DISCLOSURE
 

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 driverís license or other identifying documents
 

 


 

 

 

 

 

SECTION C - TRANSACTION ACCOUNT DISCLOSURE INFORMATION

 
 

Have you had a transaction account at this or another financial institution within 12 months before making this application?  

Name of Institution ________________________________________

 

Have you had a transaction account closed by a financial institution without your consent within 12 months before making this application?                

REASON __________________________________

 

Have you been convicted of a criminal offense because of the use of  a check or other similar item within 24 months of making this application?  

 

 
-SIGNATURES-
I certify that everything I have stated in this application and on any attachments is correct.  You may keep this application whether or not it is approved.  By signing below I authorize you to verify my ChexSystems, employment and credit history.
 
APPLICANT SIGNATURE DATE   JOINT APPLICANT SIGNATURE      DATE
 
__________________________ ______________________ ___________ _________________________ ______________________ ___________
 

 

In the event we would be unable to contact you using the telephone number and address that you have provided on this application, please list the name, address, and telephone number of someone who will be able to provide us with your updated contact information. 
 
NAME / RELATIONSHIP ADDRESS PHONE