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					Online Certificate of Deposit Application
Earn High Interest Without Risk
Please fill out the form below to submit your Appalachian Community Bank Online CD
application. *required field      For any questions please call: 706-276-8232
Are you currently a customer of: Please Select
   * I have read and I understand all the disclosures on the previous pages.
* Please select a Certificate of Deposit Rate:
       6 Month

       12 Month

       18 Month
  * Opening Deposit: $
  Special Titling Instructions:
   (If you want any titling besides the name in which the account is opened.)
      Single Account                 Joint Account (the fields that are required for the primary account
                                                                               owner (*) will also be required for the Co-Owner)
   *Selection of Single Account or Joint Account is required

Primary Account Owner:
(The name in which interest will be reported for income tax purposes.)
Your Full Name:*
Email Address:*
(if you do not have an email address, just put in N/A)

Date of Birth:*
Mother's Maiden Name:
Employer:
Employer Phone Number:
ID Number:* (SSN or Tax ID)
Telephone (home phone w/area code)*
Telephone (cell phone w/area code)

Street Address:*
City:*
State:*                                 Zip Code:*
*Mailing Address selection required
     Mailing Address is the same as above                Mailing Address is different, enter below

Mailing Address:
City:
State:                        Zip Code:
Driver's License Number:*
Date of Issue:*
Date of Expiration:*
State of Issue:*
Co-Owner
Co-Owner Full Name:
Identification Number:
Date of Birth:
Mailing Address:
City:
State:                    Zip Code:
Telephone (homephone w/area code):

Co-Owner Street Address:
Co-Owner City:
Co-Owner State:
Co-Owner Zip Code:
Co-Owner Driver's License Number:
Co-Owner Date of Issue:
Co-Owner Date of Expiration:
Co-Owner State of Issue:



Taxpayer Identification Number Certification/Backup Withholding:
Please check the first box below indicating it is a true statement, and any of the remaining boxes
that apply to you.
    I, the primary account holder, as required by federal law, certify under penalties of perjury
that the number shown above as my Taxpayer Identification Number(s) (TIN) or, the Social
Security Number(s) (SSN) shown above is correct. (required selection below)
        I am not subject to backup withholding either because I have not been notified that I am
        subject to backup withholding as a result of a failure to report all interest or dividends, or
        the Internal Revenue Service has notified me that I am no longer subject to backup withholding.
         I am subject to back withholding.
How did you learn about Appalachian Community Bank?

Please Select

Comments or questions (optional):




Online Certificate of Deposit Funding Options
Earn High Interest Without Risk

Please Select a Funding Option:

    Wire Transfer—See instructions
     The wire is to be initiated by the customer.
     Wiring Instructions for Appalachian Community Bank:
     1.) Wire funds to:             2.) Further credit to:
     Bankers Bank in Atlanta, GA    Appalachian Community Bank
     Routing # 061003415            Routing # 061104822
     3.) Final credit to:
     Customers name and Appalachian Community Bank Account Number: 84363

    Electronic Funds Transfer

    I authorize Appalachian Community Bank to initiate the Electronic Funds Transfer
    by providing the information below:

    Financial Institution Name (where the money is being sent from)

    Routing #
    Account #
    Amount (required)
Check by Mail:
Please send all checks to:

Appalachian Community Bank
Attn: Online Banking Department
P.O. Box G
Ellijay, GA 30540

If we do not receive funds to open the deposit account within 5 business days after the date you submit
your application, we may change the rate at which we can open your account. Any rate change will be in
line with the rates we offer on similar deposits in that period between 6 and 15 days of your application
date. If we don't receive funds within 15 days of your submitting the application, we will consider that you
have changed your mind and withdrawn your application. If, for any reason, we are unable to open the
account you have requested, all funds will be promptly returned to you and no interest will accrue.



                                    Submit              Print

  Clicking "Submit" more than once will result in duplicate applications being submitted.

  "Submit" — "This option allows you to send this application to the bank via the web
  using a secure server."
  "Print" — "This option allows you to print out the application so that you can bring or
  mail the application to the bank."

				
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posted:10/30/2008
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