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REGULAR CHECKING APPLICATION
Attention:  Fill in all the information, print the form on your printer, and then fax it or mail to:
Kentland Bank
P.O. Box 145
Kentland, IN 47951
219-474-5155
Fax 219-474-5071		 Lake Village
P.O. Box 245
Lake Village, IN 46349
219-992-3313
Fax 219-992-2501		 Rensselaer
P.O. Box 164
Rensselaer, IN 47978
219-866-4142
Fax 219-866-4514		 Roselawn:
P.O. Box 304
Roselawn, IN 46372
219-345-4646
Fax 219-345-2038
Type of Account:
  Individual   Joint
Ownership Information:
First Name  
Last Name  
e-mail Address  
Social Security #  
Driver's License Number     State
Date of Birth (mm/dd/yy)  
Place of Birth  
Are you a U.S. Citizen?  yes     no
Street Address  
City,

State

 ,
 
Zip-Plus 4 -
Home Phone Number  -
Work Phone Number  -
Joint Account Owner Information:
Please fill out this section if you selected joint account ownership.
First Name  
Last Name  
Social Security #  
Date of Birth (mm/dd/yy)  
Are you a U.S. Citizen?  yes     no
Deposit Information:
Initial Deposit  
Initial Deposit Type  
If depositing by credit card...  
Name on Card  
Card Type  
Card Number  
Expires (mm/dd/yy)  
 I/we certify that the information supplied on this application is true. I/we authorize Kentland Bank to verify the information and to obtain a copy of my current credit report for the purpose of extending credit.
 
OUR PEOPLE CARE!  It's our policy . . . It's our promise.