Single Owner (individual)
Joint (right to survivorship)
Joint (no right to survivorship)
Payable on Death (POD)

Primary Account Owner

Name (First M. Last)
Date of Birth (mm/dd/yyyy)
City, State Zip-Plus4 , -
Home Phone Number ( ) -
Work Phone Number ( ) -
Driver's License Number State

Joint Account Owner (if you selected joint account ownership)

Name (First M. Last)
Date of Birth (mm/dd/yyyy)
Driver's License Number State

Payable on Death Beneficiary (if you selected POD ownership)

Name (First M. Last)
Phone Number ( ) -
City, State Zip-Plus4 , -

Deposit Information

Initial Deposit $
Initial Deposit Type

CD Information

Please select what term you would like from the following table:

  Deposit Term
91 Day
182 Day
1 Year
18 Months
2 Years
3 Years
4 Years
5 Years
5 Year Jump Rate
7 Month Special
14 Month Special

Automatically renewable
Interest will be credited .
Interest options:
    Add interest to CD.
    Credit interest to my account # .

Taxpayer Identification Number Certification

Social Security Number(s) The Social Security Number(s) shown above is my correct SSN.

Backup Withholding 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.

Exempt Recipients I am an exempt recipient under the Internal Revenue Service Regulations.

Nonresident Alien 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.

I certify under penalties of perjury the statements checked in this section are true.

I authorize KANZA 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.

I would like to access this account through Online Banking.