Application
				TrustReporter Account Access
Yes, I want to subscribe to TrustReporter Account Access through the Internet.  By signing below, I agree
that I have read the TrustReporter Account Access Agreement and will comply with the terms and conditions
therein.
1.  Subscriber Information
Name:   First		Mi	Last				Social Security/Tax ID Number
Mailing Address
City				State			Zip
Daytime Phone Number				Evening Phone Number			E:mail Address
2.  Account Information
I designate the following account(s) for my access using the TrustReporter service.
Account Number				Account Name
3.  Signature
Signature of Owner, Joint Owner, Custodian, Authorized Officer							Date
For Internal Use Only
Identification Number				User ID Assigned			Accepted By/Date
For assistance:  Phone: (563) 243-1243  ·  toll-free: (800) 243-9007  ·  www.clintonnational.com
Clinton National Bank
Attn: Kristi McCune
235 6th Avenue South
Clinton, IA 52732