New Account Application

Important Information About Procedures for Opening a New Account:

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 driver’s license or other identifying documents.


* Indicates Required Information

Acct. Holder Info

PRIMARY OWNER JOINT OWNER
Name*
Business Name
D.O.B.*
SSN*
P.O. Box
Street Address
City*
State*
ZIP*
Driver's License Number*
Driver's License State*
Employer*
Home Phone*
Work Phone*

OWNERSHIP OF ACCOUNT

Personal Accounts
Single ow ner account Joint owners account
List Beneficiaries
Commercial Accounts
DBA account   Commercial account

ACCOUNT INFORMATION

Initial Deposit
Previous Bank
Check Options
Include Driver's License on Checks   Include home phone number on checks

CHECK ONE OR MORE OF THE ACCOUNTS BELOW TO APPLY FOR:

Lagniappe Checking Student Checking Senior Checking Commercial Checking
Regular Savings Christmas Club Account Certificate of Deposit IRA

CHECK ONE OR MORE OF THE SERVICES BELOW TO APPLY FOR:

Debit Card ATM Card Safe Deposit Box Overdraft Protection
Internet Banking Merchant Processing (Businesses only)    

 

Certification
I certify that I am at least 18 years of age and I have accurately and fully completed all items on this application. Under penalties of perjury, I certify that:
  1. The social security number (SSN) and/or tax payer identification number (TIN) shown above is my correct number;
  2. I am NOT subject to backup withholding because (a) I am exempt from backup witholding, 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 Internal Revenue Service has notified me that I am no longer subject to backup withholding; and
  3. I am a U.S. person (including a U.S. resident alien). 

Or check all that apply:

  I have been notified that I am subject to backup withholding.

  I am not a U.S. citizen or resident (complete W-8) form.

The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

Please note, this application is subject to verification and approval. In order for us to process your application correctly, we may need to contact you to verify some of the information or request additional documentation. When you submit this application, you certify that everything stated above is true and accurate.  When you submit this application, you also agree that this Institution reserves the right to review your credit history through an authorized bureau.

We require that all individuals on an account must sign all account related documents in-person at one of our locations before any accounts or services are activated.

If you have any questions, please contact us at 337-432-6646, or by e-mail at info@basilebank.com.

By clicking below, I hereby certify that everything I have stated above is correct. You may keep this application whether or not it is approved. By clicking below, I authorize you to check my credit and employment history and verify other information which I have provided to you.