Social Security Number:___________________________ Date of Birth:__________________________

E-mail Address:__________________________________ Mother’s Maiden Name:_________________

Address:_____________________________________________________________________________

Home Telephone #:___________________________Work Telephone #:__________________________

Please list all account numbers on which you are a signer and would like to access. (All accounts must
have the same Owner and Tax Identification Number.)

__________________       __________________         __________________         __________________

__________________      __________________          __________________          __________________

By signing below, I certify that the information is true and correct. I acknowledge that in consideration of Vinton County National Bank or Ross County Banking Center accepting this account and any other account(s) or service(s) whether existing or new, I agree to be bound by the Truth In Savings, Electronic Funds Disclosure, and other disclosures governing such account(s) or service(s), as amended from time to time and any other account opening documentation executed by me with the bank. All instructions delivered by Online access will be deemed to be my written authorization to charge or credit my accounts for transactions indicated. If I am under the age of 18, the undersigned parent/guardian agrees to be bound by the above on my behalf.
Account Owner’s Signature

_______________________________________ ___________________________________________
                               Signer                                                                   Parent/Guardian (if applicable)