Banking Service Request Form

BANKING SERVICE REQUEST FORM

Request Summary

Date of Request:

Client Name:    Existing Account No.:

Applicant Information

Individual    Sole Proprietorship    Corporation    LLC

Partnership    Trust    Other:

Existing Account Information

Account Title:    Branch/Office:

Account Type: Checking    Savings    Loan    Other

Services Requested

Select the service(s) to be implemented or changed. Check all that apply.

Wire Transfer (outgoing)    ACH Origination    Online Banking Enrollment    Debit/ATM Card Request

Checkbook Request    Stop Payment    Account Closure    Add/Remove Authorized Signatory

Other:

Service Details — Provide applicable details below

ABA / SWIFT / IBAN:    Amount:    Value Date:

Effective Date for Origination:    ACH Purpose / Detail:

Preferred Username:    Access Level: View Only    Initiate Transactions

Request Type: New Card    Replacement    Change Daily Limit

Checkbooks requested (qty):    Stop Payment — Check No.:

Stop Payment — Amount:    Check Date:

ID Type / Number:    DOB:

Required Attachments

Attach copies as applicable. Bank will not process requests without required documentation.

Voided check / bank verification    Articles of organization / incorporation    Corporate resolution / signing authority

Government-issued ID copy    Other documents:

Terms, Certifications and Authorization

By signing below, the applicant certifies that the information provided on this form and in any supporting documentation is true, complete and accurate. The applicant authorizes the bank to process the requested services, open or close accounts, add or remove authorized signatories, and to rely on any specimen signatures and documentation supplied. The applicant agrees to be bound by the bank's standard terms, fees and policies applicable to the services requested and acknowledges that certain services may be subject to separate agreements and additional documentation.

The applicant authorizes the bank to obtain and verify credit, identity and background information as required to evaluate and administer the requested services and acknowledges the bank's right to refuse or suspend services for compliance, regulatory, or risk reasons. The applicant agrees to indemnify and hold the bank harmless from claims arising from the bank's good faith reliance on information, instructions, or signatures provided by the applicant or its authorized representatives.

I certify that I have the authority to make this request on behalf of the account holder and that I accept the terms set forth above.

Additional Instructions / Notes

For Bank Use Only

Branch / Unit:    Processed Date:

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