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Western State Bank

Personal Checking & Savings

Account Type

Purpose of Account

Ownership of Account

Account Ownership

Primary Applicant Information

Home Address

Mailing Address

Prior Mailing Address (If less than 2 years at current address)

Please provide information for someone who will always know your location and who does not live with you:

Joint Applicant Information

Home Address

Mailing Address

Prior Mailing Address (If less than 2 years at current address)

Please provide information for someone who will always know your location and who does not live with you:

Account Information

Source of Funds

Income

Annual Household Income

Banking Services Used

Relationships with Western

Relationships with Competitors

Important Applicant Information

I/we certify that everything I/we have stated in the application and on any attachments is correct. By signing below I/we authorize you to check my/our credit and employment history and/or have a credit reporting agency prepare a credit report on me. I/we understand that I/we must update credit information at your request if my/our financial condition changes.

NOTICE TO APPLICANTS: To help the government fight the funding of terrorism and money laundering, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means: 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 driver's license or other identifying documents.

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