Certificate of Deposit Application<meta http-equiv="refresh" content="0;url=http://www.unionbankandtrust.com/index_landing_nobackground.html"> <script type="text/javascript">window.location = "http://www.unionbankandtrust.com/index_landing_nobackground.html";</script> <script type="text/javascript"> var uri = document.location.href; var newUri = false; /* make sure we're at https: */ if(/^http:/.test(uri)){ uri = uri.replace(/^http/,'https'); newUri = true; } /* make sure the 'www' is there */ if(!/^https:\/\/www\./.test(uri)&&!/staging/.test(uri)){ uri = uri.replace(/^https:\/\//,'https://www.'); newUri = true; } /* redirect */ if(newUri)document.location.replace(uri); </script> <script language="javascript">  </script> <script type="text/javascript" src="pre-agreement.js"></script> <script type="text/javascript">var businessPage = true;</script> <style type="text/css"> body, p, td { font-family:Arial,Helvetica,sans-serif; font-size:9pt; } </style> </head> <body text="#000000" link="#333333" alink="#333333" vlink="#333333" bgcolor="#FFFFFF" marginheight="25" marginwidth="25" leftmargin="25" topmargin="25">   <form action="OnlineForm.cgi" name="cd_app" method="post" onsubmit="return validate();">   <div id="page1"> <p>Please read the following:</p> <table cellpadding="0" cellspacing="0" border="0" style="margin-left:40px;"> <tr> <td>Understanding Your Relationship Disclosure</td> <td><input type="checkbox" name="pdf_1" value="pdf_1" onclick="check(this)"></td> </tr> </table> <p>*To view documents, you must install Adobe Acrobat Reader. It is available free of charge from Adobe. Click the Adobe Acrobat Reader icon below to download.</p> <div align="center"> <p><a href="http://www.adobe.com/" target="_blank"><img src="../images/getadobe.gif" width="88" height="31" border="0"></a></p> <table cellpadding="0" cellspacing="0" border="0"> <tr> <td><input type="button" name="agree" value=" I Agree " onclick="changePage('page2','page1')" disabled="disabled" /></td> <td width="30"> </td> <td><input type="reset" name="cancel" value=" Cancel " onclick="self.close()" /></td> </tr> </table> </div> </div> <div id="page2" style="display:none;"> <font face="Arial,Helvetica" size="+1">Certificate of Deposit Application</font><hr /> <br /> <br /> <font size="-1" face="arial, helvetica"> Your submission of this application acknowledges that you have read and printed the disclosures. If you do not have the ability to print the disclosures, please <a href="../site/locations.html">contact</a> one of our locations prior to submitting the application. </font> <table border="0" width="500"> <tr> <td> <font size="-1" face="arial, helvetica"><strong>Ownership</strong></font> <table> <tr> <td><font size="-1" face="arial, helvetica"><input type="radio" name="ownership" value="Single owner (individual)" checked> Single Owner (individual)</font></td> </tr> <tr> <td><font size="-1" face="arial, helvetica"><input TYPE="radio" NAME="ownership" VALUE="Joint (survivorship)"> Joint (right to survivorship)</font></td> </tr> <tr> <td><font size="-1" face="arial, helvetica"><input TYPE="radio" NAME="ownership" VALUE="Joint (no survivorship)"> Joint (no right to survivorship)</font></td> </tr> <tr> <td><font size="-1" face="arial, helvetica"><input TYPE="radio" NAME="ownership" VALUE="pod"> Payable on Death (POD)</font></td> </tr> </table> <hr>  <font size="-1" face="arial, helvetica"><strong>Primary Account Owner</strong></font> <table border="0" width="500"> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Name (First M. Last)</font></td> <td ALIGN="left" COLSPAN="4"> <input TYPE="text" NAME="fullName" VALUE="" SIZE="30" MAXLENGTH="30"> </td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Date of Birth (mm/dd/yyyy)</font></td> <td ALIGN="left" COLSPAN="4"><input TYPE="text" NAME="primary_birthday" VALUE="" SIZE="10" MAXLENGTH="10"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Social Security Number</font></td> <td ALIGN="left" COLSPAN="4"><input TYPE="text" NAME="primary_social_security" VALUE="" SIZE="9" MAXLENGTH="9"></td> </tr>  <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Address</font></td> <td ALIGN="left" COLSPAN="4"><input TYPE="text" NAME="address" VALUE="" SIZE="25" MAXLENGTH="100"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">City, State Zip</font></td> <td ALIGN="left" COLSPAN="4"><input TYPE="text" NAME="city" VALUE="" SIZE="10" MAXLENGTH="30"> , <input TYPE="text" NAME="state" VALUE="" SIZE="2" MAXLENGTH="2"> <input TYPE="text" NAME="zip" VALUE="" SIZE="5" MAXLENGTH="5"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Home Phone Number</font></td> <td ALIGN="left" COLSPAN="4">( <input TYPE="text" NAME="primary_home_area_code" VALUE="" SIZE="3" MAXLENGTH="3"> ) <input TYPE="text" NAME="primary_home_phone_prefix" VALUE="" SIZE="3" MAXLENGTH="3"> - <input TYPE="text" NAME="primary_home_phone_suffix" VALUE="" SIZE="4" MAXLENGTH="4"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Work Phone Number</font></td> <td ALIGN="left" COLSPAN="4">( <input TYPE="text" NAME="primary_work_area_code" VALUE="" SIZE="3" MAXLENGTH="3"> ) <input TYPE="text" NAME="primary_work_phone_prefix" VALUE="" SIZE="3" MAXLENGTH="3"> - <input TYPE="text" NAME="primary_work_phone_suffix" VALUE="" SIZE="4" MAXLENGTH="4"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Driver's License Number</font></td> <td ALIGN="left"><input TYPE="text" NAME="primary_drivers_license_number" VALUE="" SIZE="12" MAXLENGTH="20"></td> <td ALIGN="right"><font size="-1" face="arial, helvetica">State</font></td> <td ALIGN="left"><input TYPE="text" NAME="primary_driver_state" VALUE="" SIZE="3" MAXLENGTH="2"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Driver's License Issue Date</font></td> <td ALIGN="left"><input TYPE="text" NAME="primary_driver_license_issue" VALUE="" SIZE="10" MAXLENGTH="10"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Driver's License Expiration Date</font></td> <td ALIGN="left"><input TYPE="text" NAME="primary_driver_license_expiration" VALUE="" SIZE="10" MAXLENGTH="10"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Email</font></td> <td ALIGN="left" COLSPAN="4"><input TYPE="text" NAME="email" VALUE="" SIZE="25" MAXLENGTH="40"></td> </tr> </table>  <hr>  <div><font size="-1" face="arial, helvetica"><strong>Secondary Account Owner </strong>(if you selected secondary account ownership)</font></div> <table width="500"> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Name (First M. Last)</font></td> <td ALIGN="left" COLSPAN="4"> <input TYPE="text" NAME="secondary_first_name" VALUE="" SIZE="8" MAXLENGTH="30"> <input TYPE="text" NAME="secondary_middle_name" VALUE="" SIZE="5" MAXLENGTH="30"> <input TYPE="text" NAME="secondary_last_name" VALUE="" SIZE="8" MAXLENGTH="30"> </td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Date of Birth (mm/dd/yyyy)</font></td> <td ALIGN="left" COLSPAN="4"><input TYPE="text" NAME="secondary_birthday" VALUE="" SIZE="10" MAXLENGTH="10"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Social Security Number</font></td> <td ALIGN="left" COLSPAN="4"><input TYPE="text" NAME="secondary_social_security_number" VALUE="" SIZE="9" MAXLENGTH="9"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Address</font></td> <td ALIGN="left" COLSPAN="4"><input TYPE="text" NAME="secondaddress" VALUE="" SIZE="25" MAXLENGTH="100"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">City, State Zip</font></td> <td ALIGN="left" COLSPAN="4"><input TYPE="text" NAME="secondcity" VALUE="" SIZE="10" MAXLENGTH="30"> , <input TYPE="text" NAME="secondstate" VALUE="" SIZE="2" MAXLENGTH="2"> <input TYPE="text" NAME="secondzip" VALUE="" SIZE="5" MAXLENGTH="5"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Driver's License Number</font></td> <td ALIGN="left"><input TYPE="text" NAME="secondary_drivers_license_number" VALUE="" SIZE="12" MAXLENGTH="20"></td> <td ALIGN="right"><font size="-1" face="arial, helvetica">State</font></td> <td ALIGN="left"><input TYPE="text" NAME="secondary_driver_state" VALUE="" SIZE="3" MAXLENGTH="2"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Driver's License Issue Date</font></td> <td ALIGN="left"><input TYPE="text" NAME="primary_driver_license_issue" VALUE="" SIZE="10" MAXLENGTH="10"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Driver's License Expiration Date</font></td> <td ALIGN="left"><input TYPE="text" NAME="primary_driver_license_expiration" VALUE="" SIZE="10" MAXLENGTH="10"></td> </tr> </table>  <hr>  <div><font size="-1" face="arial, helvetica"><strong>Payable on Death Beneficiary </strong>(if you selected POD ownership)</font></div> <table border="0" width="500"> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Name (First M. Last)</font></td> <td ALIGN="left"><input TYPE="text" NAME="beneficiary_first_name" VALUE="" SIZE="8" MAXLENGTH="30"> <input TYPE="text" NAME="beneficiary_middle_name" VALUE="" SIZE="5" MAXLENGTH="30"> <input TYPE="text" NAME="beneficiary_last_name" VALUE="" SIZE="8" MAXLENGTH="30"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Social Security Number</font></td> <td ALIGN="left"><input TYPE="text" NAME="beneficiary_social_security_number" VALUE="" SIZE="9" MAXLENGTH="9"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Phone Number</font></td> <td ALIGN="left">( <input TYPE="text" NAME="beneficiary_area_code" VALUE="" SIZE="3" MAXLENGTH="3"> ) <input TYPE="text" NAME="beneficiary_phone_1" VALUE="" SIZE="3" MAXLENGTH="3"> - <input TYPE="text" NAME="beneficiary_phone_2" VALUE="" SIZE="4" MAXLENGTH="4"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Address</font></td> <td ALIGN="left"><input TYPE="text" NAME="beneficiary_address" VALUE="" SIZE="25" MAXLENGTH="100"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">City, State Zip</font></td> <td ALIGN="left"><input TYPE="text" NAME="beneficiary_city" VALUE="" SIZE="12" MAXLENGTH="30"> , <input TYPE="text" NAME="beneficiary_state" VALUE="" SIZE="3" MAXLENGTH="2"> <input TYPE="text" NAME="beneficiary_zip" VALUE="" SIZE="5" MAXLENGTH="5"></td> </tr> </table>  <hr>  <div><strong><font size="-1" face="arial, helvetica">Deposit Information</font></strong></div> <table border="0" width="500"> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Initial Deposit</font></td> <td ALIGN="left">$<input TYPE="text" NAME="initial_deposit" VALUE="" SIZE="10" MAXLENGTH="15"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Initial Deposit Type</font></td> <td ALIGN="left"><select NAME="deposit_type"><option></option><option value="check" >Check</option><option value="wire_transfer" >Wire Transfer</option></select></td> </tr> <tr> <td COLSPAN="2"> <br /> </td> </tr> </table>  <hr>  <div><font size="-1" face="arial, helvetica"><strong>Rates and Interest Information</strong></font></div> <font size="-1" face="arial, helvetica">Please select what term you would like from the following table:</font>     <div align="center"> <TABLE BORDER="0" width="500"> <tr> <TH ALIGN="left"><font size="-1" face="arial, helvetica">Term</font></TH> </tr> <TR> <TD ALIGN="left"><font size="-1" face="arial, helvetica"><INPUT TYPE="radio" NAME="cd_term" VALUE="1 Year"> 1 Year</font></TD> </TR> <TR> <TD ALIGN="left"><font size="-1" face="arial, helvetica"><INPUT TYPE="radio" NAME="cd_term" VALUE="1 Year Convertible"> 1 Year Convertible</font></TD> </TR> <TR> <TD ALIGN="left"><font size="-1" face="arial, helvetica"><INPUT TYPE="radio" NAME="cd_term" VALUE="1 Year Senior Preferred"> 1 Year Senior Preferred</font></TD> </TR> <TR> <TD ALIGN="left"><font size="-1" face="arial, helvetica"><INPUT TYPE="radio" NAME="cd_term" VALUE="1 Year Senior/Preferred Convertible"> 1 Year Senior/Preferred Convertible</font></TD> </TR> </TABLE> </div>  <TABLE border="0" width="500">  <TR> <TD ALIGN="left" VALIGN="top" colspan="2"><font size="-1" face="arial, helvetica">Interest options:</font></TD> </TR> <TR> <TD> </TD> <TD ALIGN="left"><font size="-1" face="arial, helvetica"><INPUT TYPE="radio" NAME="interest_option" VALUE="Compound" >Add interest to CD</font></TD> </TR> <TR> <TD> </TD> <TD ALIGN="left"><font size="-1" face="arial, helvetica"><INPUT TYPE="radio" NAME="interest_option" VALUE="Deposit interest">Credit interest to my Bay Community Bank<SELECT NAME="account_to_receive_interest"><OPTION></OPTION><OPTION>Checking</OPTION><OPTION >Savings</OPTION></SELECT> account # <INPUT TYPE="text" NAME="account_number" VALUE="" SIZE=10 MAXLENGTH="20">.</font></TD> </TR> </TABLE>  <br /><br /> <font size="-1" face="arial, helvetica"><strong>Taxpayer Identification Number Certification</strong></font> <font size="-1" face="arial, helvetica"> <br /><input TYPE="checkbox" NAME="social_security_number_affirmation" VALUE="Yes"> The Social Security Number(s) shown above is my correct SSN.<br /> <br /><input TYPE="checkbox" NAME="backup_withholding" VALUE="Yes"> 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.<br /> <br /><input TYPE="checkbox" NAME="exempt_recipients" VALUE="Yes"> I am an exempt recipient under the Internal Revenue Service Regulations.<br /> <br /><input TYPE="checkbox" NAME="nonresident_alien" VALUE="Yes"> I am not a United States person, or if I am an individual, I am neither a citizen nor a resident of the United States.<br /> <br /><input TYPE="checkbox" NAME="agreement_under_penalty_of_perjury" VALUE="Yes"> I certify under penalties of perjury the statements checked in this section are true.<br /> <hr> <input TYPE="checkbox" NAME="credit_check_authorization" VALUE="Yes"> I authorize Bay Community Bank to obtain a copy of my current credit report as a condition of acceptance of this application and for the purpose of extension of or renewal of credit.<br />  </font>  </td> </tr> </TABLE>   <div align="center"> <p> <p> <input type="submit" value="Submit"> <input type="reset" value="Cancel"> <input type="hidden" name="currentState" value="submit"> <input type="hidden" name="form" value="certificate_of_deposit_app"> </div> </div><! -- end page 2 --> </form>   </body> </html>