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Welcome to Mid Penn Bank On-Line. This new account application is intended for current customers or those moving to our geographic area who will be banking with us.

Our primary service area includes the following counties of Pennsylvania: Dauphin, Cumberland, Schuylkill and Northumberland.

Our secondary service area includes portions of the following counties of Pennsylvania: Perry, Juniata, Snyder, York, Lancaster, Lebanon and Adams County.

We are committed to providing you with the best customer service possible which is why we must limit our service area.

Account opening restrictions: Accounts will not be processed until deposits are received. We reserve the right to not open a transactional account if it is out of our service area. Prospective depositors must be of legal age to apply for a deposit account, otherwise, a parent or guardian may be required as a co-owner of the account to open the account.


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, address, date of birth
and driver's license or other identifying documents.
TYPE OF ACCOUNT(S) TO OPEN

Click here to apply for an ATM/Check Card

Comments / Notes:

If you would like to add any comments / notes regarding the account you are
opening, type information in box above.
  CHECKING - NOW - MONEY MARKET ACCOUNTS
  Ownership:   Individual (Single Owner)
    Joint (With Right of Survivorship)
    In Trust for
Amount of Initial Deposit: $
    Transfer initial deposit from my acct #  
     Checking   Savings
    I will enclose a check along with my signed signature form for my initial deposit.
Type of Checking:  
Do you want this account linked to your on-line session?
  Yes   No
Do you want this account linked to your MAC/Debit Card?
  Yes   No
ESCROW SUB-ACCOUNT (Click here for form)
  SAVINGS
  Ownership:   Individual (Single Owner)
    Joint (With Right of Survivorship)
    In Trust for
Amount of Initial Deposit: $
    Transfer initial deposit from my acct #  
     Checking   Savings
  I will enclose a check along with my signed signature form for my initial deposit.
 Type of Savings:  
Do you want this account linked to your on-line session?
  Yes   No
Do you want this account linked to your MAC/Debit Card?
  Yes   No
  CERTIFICATE OF DEPOSIT
  Ownership:   Individual (Single Owner)
    Joint (With Right of Survivorship)
    In Trust for
Amount of Initial Deposit: $
    Transfer initial deposit from my acct #  
     Checking   Savings   Certificate of Deposit
    I will enclose a check along with my signed signature form for my initial deposit.
Term of Investment:   Specify Special term:
 
Interest Options:   Credit Interest to my
account #
 
 
Add interest to CD.
Do you want this account linked to your on-line session?
    Yes   No
  CHRISTMAS / HOLIDAY CLUB ACCOUNT
  Ownership:   Individual (Single Owner)
      Joint (With Right of Survivorship)
  Weekly Automatic Deduction: $
  Please deduct My Payment Every Friday From  
     
Account #:
  
  I wish to have Mid Penn Bank debit the above account for any Christmas club payments which are currently required to update my payment schedule since I have opened my account later than the start of the club account date, which was October 27, 2000. I understand that this debit will be taken as a lump sum from my account.
  I do not wish to bring my new Christmas Club account payments current. I understand a check will be mailed to me at maturity for the funds that I have deposited into my Christmas Club from the date of opening until maturity, but this amount will not reflect my interest earned.
  ALL-PURPOSE CLUB ACCOUNT
  Ownership:   Individual (Single Owner)
      Joint (With Right of Survivorship)
  I would like a check for the balance of my All-Purpose Club mailed to me on 15th, *.

* You may choose your own maturity date, up to 2 years from the date you open your account. This account will mature on the 15th day of the month in the year you choose.

BANK CODE:
Bank Code
PRIMARY ACCOUNT OWNER:
Last Name
 First Name
 MI
Social Security No.
 Date of Birth
Street Address
P.O. Box (if applicable)
City
 State
 Zip
Home Phone
 Work Phone
Driver's License Number
 DL State
 E-mail
Driver's License Issue Date
 Driver's License Expiration Date
JOINT ACCOUNT OWNER (if you selected joint account ownership):
Last Name
 First Name
 MI
Social Security No.
 Date of Birth
Driver's License Number
 DL State
 E-mail
Driver's License Issue Date
 Driver's License Expiration Date
IN TRUST FOR:
Last Name
 First Name
 MI
Social Security No.
 Date of Birth
TAXPAYER IDENTIFICATION NUMBER CERTIFICATION:
Please check all the boxes below that are applicable to you. (Some of the boxes are already pre-checked for your convenience.)
Primary Owner: Joint Owner:
Social Security Number: The social security number shown above is my correct SSN.
Social Security Number. The social security number 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 failure to report all interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding.
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 failure to report all interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding.
I certify under penalty of perjury that I am a U.S. citizen.
I certify under penalty of perjury that I am a U.S. citizen.
Exempt Recipients: I am an exempt recipient under the Internal Revenue Service Regulations.
Exempt Recipients: I am an exempt recipient under the Internal Revenue Service Regulations.
Non-Resident 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.
Non-Resident 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 certify under penalties of perjury the statements checked in this section are true.
I would like to access this account through On-Line Banking.
I would like to access this account through On-Line Banking.
I understand that a Truth in Savings Disclosure and the Terms and Conditions that pertain to this account will be mailed to me within 3 business days of the submission of my account application. I will read the disclosures and if I have any questions pertaining to the disclosure or the account terms and conditions I will notify the bank immediately.
I understand that a Truth in Savings Disclosure and the Terms and Conditions that pertain to this account will be mailed to me within 3 business days of the submission of my account application. I will read the disclosures and if I have any questions pertaining to the disclosure or the account terms and conditions I will notify the bank immediately.
I agree with all the items marked above, including those that are pre-checked, and the ones which were checked by me.
I agree with all the items marked above, including those that are pre-checked, and the ones which were checked by me.
SIGNATURE FORM
Primary Owner: Joint Owner:
X_____________________________ X_____________________________
Signature of Primary Owner
Signature of Joint Owner
If you have the capability to print this form, please select the "print form" button below, sign the signature form and mail this along with your deposit, (if you are not transferring funds from an existing account), to:

Mid Penn Bank, On-Line Office Manager
349 Union Street
Millersburg, PA 17061.

If you wish to submit your account information electronically, or if you cannot print this form, select the "send" button below. You may be required to visit one of our offices to sign a signature card, depending on the type of account you open. We will notify you by e-mail if you will be required to go to one of our offices. Please be prepared to provide photo identification at that time. If necessary, which office would you prefer to go to: