Customer Identification Verification

Individual/Business

*Name
Account #
Opening Date
*SSN or Taxpayer ID
*Date of Birth
*Home Phone
Work Phone
Cell Phone
*Physical Address
*City, State, Zip
*Mailing Address (If Different)
*City, State, Zip

ID Verification Method

*Type
*Number
*Place of Issuance
*Date of Issuance
*Expiration Date
Non-Documentary Method Used for ID Verification
Discrepancies
Discrepancy Resolution

*Required

The information I have provided is correct to the best of my knowledge. I have been informed of the Customer Identification requirements of the USA Patriot Act. I authorize the Bank to check credit, prior banking activity, employment history, and/or other information should it deem necessary to confirm my identity and evaluate my account status in compliance with the USA Patriot Act of 2001 and related laws and regulations.

Account Owner Signature or Authorized Representative	Date
Account Owner Signature or Authorized Representative	Date

Please note that applications submitted will not be processed until we have verified your information and identity by having you visit one of our Cornerstone National Bank offices. A Customer Service Representative will contact you within 2 business days of your request.