DEBI TCARD Form
Account Holder Name: DOB:
Phone: Social Security Number:
Address: City: State: Zip:
Checking Account Number:
APPLICATION FOR FIRST TIME CARDHOLDERS
Name on Card:
AUTHORIZATION: I agree that use of the Card will be subject to the terms and conditions in the Deposit Account Agreement and Disclosure and Regulation E Disclosure that have been provided to me. I authorize the Financial Institution to make any investigation of my credit, either directly or through any agency. I understand that the Financial Institution will retain this application and any other credit information, even if this Card is not granted. I agree not to use this Card for any illegal activity. The undersigned acknowledges the receipt of and agrees to the terms of this Card.
FOR INTERNAL USE
Date Taken:
CARD CHANGE INFORMATION
Card Number:
Reorder Same Card Number:
Instant Issue:
Order New Card Number: Instant Issue?:
Temporary POS limit request:
Temporary ITM limit request: Date to be lowered: Permanent limit request (Officer Approval Required) :
Account(s) to be linked to Card: Officer Approval:
Customer Signature: Date:
UPDATED 1/2023