Print Form Tampa Road Oldsmar FL Office FAX e mail by legalstuff1

VIEWS: 25 PAGES: 1

									                                                                                                                                               Print Form

                                                                                                                 e-mail questions to:
                                                            3711 Tampa Road
                                                                                                                  MRoun@JeffersonBankFL.com
                                                            Oldsmar, FL 34677
                                                                                                                 KMcPhillips@JeffersonBankFL.com
                                       Office: 813-855-7500                     FAX 813-855-7510                 RFasano@JeffersonBankFL.com
                                       Please contact me to open a business account:
Date
Referred by:
           IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT
The foregoing data is being gathered for the purpose of opening one or more depository accounts at Jefferson Bank of Florida. 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 or entity that opens an account. Any joint owners of a personal account or authorized signers on a business
account should submit their personal information on a separate form.

WHAT THIS MEANS TO YOU: When you open an account, we will ask for your name, company's name, address, date of birth, and other information
that will allow us to identify you and the company. We may also ask to see your driver's license, organizational documents and other identifying
documents.


                                                            Business Information
                 Legal Name:
              Street Address:
                          City:
                         State:
                    Zip Code:
                  Tax ID No.:
            Business Phone:
               Business Fax:
                        e-mail:
  Date Business Established:
   State of Legal Formation:
     State of Principal Office:
                     Industry:
      Number of Employees:
                                               Business Type
        Sole Proprietor                    C-Corporation                      S-Corporation
  General Partnership                Limited Partnership                                 LLP
    Professional Corp.                        Association                                LLC
Are You a Non-Profit Organization?          Yes            No
                                Authorized Signers and Ownership Interest
           Legal Name:                                      Title:                    Ownership %:
           Legal Name:                                      Title:                    Ownership %:
           Legal Name:                                      Title:                    Ownership %:
           Legal Name:                                      Title:                    Ownership %:
                                     Accounts that I am Interested In
Account Type
Requested:              Checking            Savings                MMDA                CD
                                            On-Line
Other Services:         Debit Card          Banking                Bill Pay            Other
Preferred Contact       Meeting             Phone                  Mail                e-mail
Method:                 Home                                       Business
                                        Organizational Documents
      Articles of Incorporation          Articles of Organization           Partnership Agreement
   Fictitious Name Certificate            Occupational License               Articles of Association
Comments:

								
To top