Personal Debit Card Application

PERSONAL DEBIT CARD APPLICATION

Applicant Information

Full legal name:

Date of birth:    Social Security Number:

Identification

Primary government ID (select all that apply):

Driver's license    Passport    State ID    Other

ID expiration date:

Account Information

Account type (select all that apply):

Checking    Savings    Money Market

Debit Card Options

Requested card features (select all that apply):

Standard debit card    Contactless tap    Premium/metal card    International ATM & POS use

Issue additional card for an authorized user? Yes    No

Authorized user's date of birth:    SSN (last 4):

Overdraft & Electronic Services

Enroll this account in overdraft protection (link eligible account)? Yes    No

Electronic statement and alerts: I opt in to electronic statements    I opt in to SMS transaction alerts

Authorization, Certifications and Disclosures

By signing below I certify that the information provided in this application is true, correct and complete to the best of my knowledge. I authorize the financial institution and its agents to obtain and verify my credit history, employment, deposit history and other information required to process this application, including consumer reporting and verification services. I further authorize the institution to provide information about me to third parties where necessary to effect card issuance, servicing or fraud control.

I understand that the debit card is governed by the institution's Debit Card Agreement and fee schedule. I agree to be bound by those terms when the card is issued to me. I acknowledge responsibility for all transactions made with my card or PIN, subject to applicable consumer protection laws. I will notify the institution immediately if my card is lost, stolen or if I suspect unauthorized use.

I consent to receive communications, disclosures and notices related to my account electronically at the email address provided unless I withdraw such consent in accordance with the institution's policy. I understand that replacement card requests, expedited delivery, and special services may carry fees as disclosed in the institution's fee schedule.

I authorize issuance of the requested debit card(s) and any additional card(s) for authorized users named above. I acknowledge that this application does not guarantee approval and that the institution reserves the right to approve or deny the request in accordance with its policies and applicable law.

Certifications (please initial where indicated)

I certify that the information in this application is true and complete.

I authorize the institution to obtain consumer reports and verify information as necessary to process this application.

I agree to the Debit Card Agreement, Electronic Funds Transfer disclosures, and the institution's fee schedule when the card is issued.

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