Account Owner and/or Authorized Signer Information Worksheet

First Name___________________MI____Last Name________________________
Street Address*___________________________________________________
*(Please note: P.O. Box holders must furnish physical address as well as mailing address)
City___________________________State___________Zip+4_____________________

Occupation or Line of Business___________________________________
(choose from list at bottom of next page)
Social Security #___________________________
Date of Birth______________________
Home Phone_______________________________
Work Phone_______________________________
Fax (if applicable)______________________
Cellular Phone___________________________
E-mail (optional)___________________________________________

Primary Identification Type & Number_________________________________________
Issuing Date and State_________________  ___________Expiration Date_____________
(OR other approved photo ID#)_________________________________________ ____________ ____________
*Note: Federal regulation requires that Bank have on file verification of customer identification.

Secondary Identification Type & Number____________________________________________________
Issuing Date and State_________________  ___________Expiration Date_____________
(OR other approved photo ID#)
Type of Account____________________________
Source of Funds________________________________________________
Check______________________________________________
Cash________
Internal Transfer______________________________________________
Account #________________________________

Special Instructions or Comments_____________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

The information I have provided is correct to the best of my knowledge. 
I/we authorize the Bank to check credit and/or employment history should it deem necessary.
Customer____________________________________________Date________________________
Customer____________________________________________Date________________________


_____________________________________   ______________________________________
Signature of account owner(s) or authorized signer(s)
Bank Use______________________________________
Branch________________________________________
Employee______________________________________
Notary Section (to be used in a non face to face application)
State of__________________________
County of_________________________
On__________________,personally appeared before me, whom I know to be person who signed this form,
and swears that he or she was present and witnessed sign his or her name to the above document.


__________________________________________
(Signature of notary officer)


Examples of Acceptable Documentary Identification
Primary Identification:
   Driver’s license with a photograph issued by the state in which the institution is located. 
   For drivers license with issue date less than one year, see paragraph **Newly issued Drivers 
   License and ID Cards
   Foreign (out-of-state) Drivers License (require a secondary identification)
   State of Nevada Issued ID Card (only accepted in conjunction with a solid second form of 
   identification, officer/supervisor approval, verification through ChexSystems and social 
   security number verification by Help Desk, issued for more than 1 year and with proof of 
   residency.) 
   See paragraph “**Newly issued Drivers License and ID Cards”
   Armed Forces Card
   Passport-US or Foreign
   Resident Alien Card (require a secondary identification)
   Mexican Government Issued ID (Matricula Consular) (require a secondary identification)
   Secondary Identification (Secondary identification accepted in conjunction with one of the 
   above forms of primary identification)
   College/Student photo identification card (verify current semester). Must document both school 
   attending, number of identification card and issue/expiration dates, if applicable
   Major credit card
   Employer identification card from a known company
   Nevada State Bank Visa Check Card (card is connected to existing checking account)
   Sheriff’s Card
   Nevada Health Card
   Union Card
Elderly or Disabled Individuals (Other Forms of Acceptable Identification)
   Nevada State Bank will accept certain documents for identification purposes from elderly or 
   disabled individuals who do not have generally acceptable (primary) identification. Social 
   Security, Medicare, Medicaid or other insurance card together with one of the following 
   identifications:
      Real Estate Tax Bill reflecting individual’s name and address. Information must be 
      verified through the Hill-Donnelly Cross-Reference.
      Utility Bill addressed to the individual. Address must be verified through the Hill-Donnelly 
      Cross-Reference. Note: If a telephone bill is presented, verify that the number is listed 
      under the individual’s name and call the number to verify that it is a working number.
      The individual’s social security number must be verified through ChexSystems. If the account 
      is opened, the signature card must be noted “Elderly” or “Disabled”. Officer/supervisor 
      approval must be obtained and evidenced by their initials on the signature card.

**Newly issued Drivers License and ID Cards that have been issued within six months to a year 
require closer scrutiny.  Branch must call the Help Desk to verify the client’s social security 
number and obtain proof of residency. Additionally, the Help Desk will verify address in 
Hill-Donnelly Cross-Reference.

Line of Business
Accountants, Auctioneers, Automobile, Boat, or Plane Dealers, Investment Brokers/Dealers, Casinos, 
Charter Companies – Plane, Bus, Boat, Check Cashing/Money Transmitters, Convenience Stores, 
Currency Exchange Houses, Deposit Brokers, Elected/Appointed Government, Officials/Campaigns, 
Grocery Stores and Supermarkets, High Balance Accounts, Import/Export Companies, Jewelry, Gem, 
Precious Metals, Lawyers, Leather Goods Stores, Machine Parts Manufacturers, Non-profit, 
Non-governmental, Charitable Org., Offshore Corporations/Banks, Parking Lots/Garages, Pawn Shops, 
Restaurants, Telemarketers, Travel Agencies, Other