APPLICATION FOR DEPOSIT ACCOUNTS
NOTE: HIGH PLAINS BANK WILL ONLY OPEN ACCOUNTS FOR CUSTOMERS LOCATED WITHIN OUR TRADE AREAS IN
COLORADO. If you wish to continue, please complete the information requested and print this form. By submitting the
information below, you are authorizing High Plains Bank to verify previous banking relationships with
ChexSystems/Qualifile.
Important Information About Procedures For Opening a New Account: 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 who opens
an account. What this means for you: When you open an account, we will ask for your name, addresss, date of birth and other information that
will allow us to identify you. We will also ask to see your Driver's License or other identifying documents of which we will make a copy for our
records.
Do you currently have an account with High Plains Bank?
 Yes  No
OWNERSHIP (SELECT ONE):
PERSONAL:
 Single Owner (Individual)
BUSINESS:
 Sole Proprietorship
 Joint
 LLC
 Payable on Death
More information will be required to open account.
 Partnership
 Corporation
 Organization/Association
 Custodian
Type of Account:
 Regular Checking  49 & Holding Checking  NOW Checking
 Student Checking  Personal Money Market Account  Regular Savings
Please mark the appropriate box 
 Young Bankers Savings  Christmas Club Savings  Certificate of Deposit
 Individual Retirement Account  Simplified Employee Pension (SEP)Accounts
 Health Savings Account Business Checking  Business Savings
 Business Interest Bearing Checking Business Money Market
Additional products you might want:
 ATM/Debit Card  Internet Banking  E-Statements  Bill Pay
PRIMARY ACCOUNT HOLDER/BUSINESS (Copy of Driver's License required unless a minor)
First Name:
Middle:
Social Security Number
Business Name: (if you selected a business account)
Employer Identification Number: (for businesses
Physical Address:
City:
State/Zip:
Home Phone:
Cell Phone:
Date of Birth:
Employed by:
ID Type and Number
Date Issued/Date Expires
Signature:
Last Name:
Mailing Address:
City:
State/Zip:
Work Phone:
E-mail Address:
Mother's Maiden Name:
Employer Address:
SECONDARY ACCOUNT HOLDER (Copy of Driver's License required unless a minor)
First Name:
Middle:
Social Security Number
Business Name: (if you selected a business account)
Employer Identification Number: (for businesses)
Physical Address:
City:
State/Zip:
Home Phone:
Cell Phone:
Date of Birth:
Employed by:
ID Type and Number
Date Issued/Date Expires
Signature:
Last Name:
Mailing Address:
City:
State/Zip:
Work Phone:
E-mail Address:
Mother's Maiden Name:
Employer Address:
PAYABLE ON DEATH BENEFICIARIES (If you selected POD ownership) or IRA BENFICIARY
First Name:
Social Security Number
Physical Address:
Middle:
Last Name:
Date of Birth:
Mailing Address:
SIGNERS OF ACCOUNT (If you selected business account) Copies of Driver's License required.
SIGNER #1
First Name:
Social Security Number
ID Type and Number
Date Issued/Date Expires
Signature:
SIGNER #2
First Name:
Social Security Number
ID Type and Number
Date Issued/Date Expires
Signature:
SIGNER #3
First Name:
Social Security Number
ID Type and Number
Date Issued/Date Expires
Signature:
SIGNER #4
First Name:
Social Security Number
ID Type and Number
Date Issued/Date Expires
Signature:
Middle:
Last Name:
Date of Birth:
Middle:
Last Name:
Date of Birth:
Middle:
Last Name:
Date of Birth:
Middle:
Last Name:
Date of Birth:
You may submit your paperwork to us in several ways:
Please provide the best way to reach you so we may set up an
appointment to finalize your application.
Phone: ___________________________________
Submit online, fax to desired location, mail to desired location
(address on our home page) or in person.
Please Mark the Correct Box for the location you will complete new
account paperwork at:
 Flagler (329 Main Ave) (719) 765-4000 - FAX (719) 765-4658
Email address: ____________________________BBBBBBBB  Bennett (235 So Ash St) (303) 644-4900 - FAX (303) 644-4904
_________________________________________________
 Longmont (600 Kimbark St) (303) 776-2265 - FAX (303) 776-3939
 Wiggins (502 Central Ave) (970) 483-7334 - FAX (970) 483-7302
THANK YOU FOR APPLYING FOR A HIGH PLAINS BANK ACCOUNT. PLEASE CALL US AT THE NUMBER PROVIDED NEXT TO YOUR
DESIRED LOCATION WITH ANY QUESTIONS.