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North Brookfield Savings Bank
Certificate of Deposit Application

Privacy Policy:
Our privacy policy protects the privacy of your personally-identifying information that you provide us online.

Account Holders must reside in State of Massachusetts.

Important Information about Procedures for Opening a New Account
Identification Procedures Requirements: 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.

Security Notice:
You should ONLY fill out this Application on-line if you are using a browser with the latest security enhancements. If you don't have the latest version, download a copy now.

Instructions:
1. Complete Application and click "Submit Application" or fax it to 508-867-7574.
2. To safeguard your privacy, QUIT your browser and restart it again after using this form. This form is NOT saved in your computer's memory when you quit your browser.
3. We will contact you with the location of our closest office for you to sign a signature card. You may also be requested to provide photocopies of your Social Security card and Driver's License, or other documentation.

Primary Joint Account Holder Information
First Name
Middle Initial
Last Name
Date of Birth
Social Security No.
Your E-mail Address
Home Phone
Driver's License No.
Driver's License State
Mailing Address
City
State
Zip
Work Phone
Joint Account Holder(with right of survivorship)
First Name
Middle Initial
Last Name
Date of Birth
Social Security No.
Your E-mail Address
Home Phone
Driver's License No.
Driver's License State
Mailing Address
City
State
Zip
Work Phone
Account Titling Information
Individual
Joint
In Trust For Name
Social Security No.
Custodial Name
Social Security No.

I/We would like to apply for the following
Certificate of Deposit:

Term Amount
3 month $
6 month $
1 year $
2 year $
3 year $
5 year $


By submitting this application, I (each person jointly and severally) apply for the Certificate of Deposit listed above. As a Certificate of Deposit owner, I am subject to all of its bylaws and rules as amended from time to time. I certify that all information given is correct.

I agree to the terms and conditions for any accounts or services that I have now or in the future, and as they change from time to time. I agree at any time you may request information from others about my credit or accounts and that you provide to others experience information about me or my accounts with North Brookfield Savings Bank.

By clicking the Submit Application button below,
I/We AGREE with the above statement