Sherburne State Bank

To Apply, having already read and accepted account disclosures, simply complete and submit application. Sherburne State Bank, upon approval, will send to you a new account packet. After executing the enclosed documents as indicated, return to us to activate your account.

A representative from Sherburne State Bank may contact you to verify your account application. Feel free to contact us with any questions you may have.

* = Required Field

All applicants must complete Section A. If you are applying for a business deposit account, complete Sections A and B. If you work in Minnesota and reside outside of Minnesota please contact us.
I am applying for: (check all that apply)	DEPOSIT ACCOUNTS Business Checking Business NOW Business Passbook Savings Business Money Market Demand CDs
SECTION A - General Information
Business Name:*	Business Type:*	Business Address:*
City:*	State: Minnesota	Zip Code:*
Mailing Address (if applicable)	City:	State: MN
Zip Code :	Business Phone:* (please include area code)	Email Address:
Fax:	Tax ID Number:	Date of Birth:*
Authorized Signer Name:*	2nd Authorized Signer Name: (if applicable)	3rd Authorized Signer Name: (if applicable)
Primary Contact:	Title:
SECTION B - Deposit Account Information
CD Term: (This is only if you choose a Certificate of Deposit)
CD Interest: (This is only if you choose a Certificate of Deposit)
Amount of Initial Deposit:
How Initial Deposit Will Be Made:	I will mail a check to Sherburne State Bank Incoming Wire Debit my existing account Account Number Debit my current Bank (You will receive a form for authorization) Bank Name Account Number ABA Number
Please Provide The Following Verification Information:
Name of Current Bank:	Address of Bank:	City:
State:	Zip Code:	Account Number :
Drivers License of Primary Contact:*
BY CLICKING ON THE SUBMIT BUTTON BELOW, I (WE) APPLY FOR THE DEPOSIT PRODUCTS LISTED ABOVE AND CERTIFY THAT ALL INFORMATION PROVIDED ABOVE IS CORRECT AND AUTHORIZE YOU TO CHECK MY (OUR) CREDIT AND VERIFY THE INFORMATION PROVIDED IN THIS APPLICATION. I (WE) ALSO CERTIFY UNDER PENALTY OF PERJURY THAT THE SOCIAL SECURITY NUMBER(S) PROVIDED ABOVE IS/ARE CORRECT AND THAT I AM NOT (WE ARE NOT) SUBJECT TO BACKUP WITHHOLDING UNDER THE INTERNAL REVENUE CODE. I (WE) UNDERSTAND THAT ADDITIONAL INFORMATION MAY BE REQUIRED BEFORE A DECISION CAN BE MADE REGARDING THIS APPLICATION. I (WE) FURTHER UNDERSTAND THAT APPROVAL BY Sherburne State Bank FOR ANY OF THE LOAN OR DEPOSIT PRODUCTS IS CONDITIONED ON MY (OUR) AGREEMENT TO ABIDE BY ALL TERMS AND CONDITIONS CONTAINED IN THE APPLICABLE LOAN AGREEMENT AND/OR DEPOSIT AGREEMENT. I FURTHER AGREE TO RETURN ANY ACCESS DEVICE FOR OBTAINING FUNDS FROM ANY TYPE OF ACCOUNT UPON DEMAND BY Sherburne State Bank.
I HAVE READ THE ABOVE STATEMENT AND AGREE TO THE TERMS SET OUT THEREIN.

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