Debit Card Application Form

Consent to Electronic Records
x
Consent to Electronic Records Consent to Electronic Records
- I consent to receive and retain disclosures electronically. By proceeding, you agree to receive all disclosures, agreements, and communications related to this application in electronic form. You may request paper copies at any time by contacting us. You confirm that you have the ability to access, download, or print these electronic records.
VALUE+-
*XRequired
Information
x
Card Type Card Type
- Personal
- Business (Please reach out to a Personal Banker)
VALUE+-
*XRequired
First Name

Middle Initial

Last Name

*X Required
Address

Address 2

City

State

Zip Code

*X Required
Telephone Number (Primary)

*X Required
Telephone Number (Secondary)

*X Required
Email

*X Required
Last four of Checking Account tied to card

*X Required
Order Type Order Type
- New Card - Brand New Relationship
- New Card - Existing Card Lost/Stolen
- Replace Existing Card (Same Card Number) - Damaged Plastic/Wear
VALUE+-
*XRequired
Card Design & Pickup Options
x
Card Type Card Type
- Default Blue
- Basehor Bobcats
- Tonganoxie Chieftains
- Lawrence Humane Society
- Piper Pirates
- Perry Kaws
- McLouth Bulldogs
- Bonner Springs Braves
- Sunflower
- Rainbow
- Carbon Fiber
- Pink
- Cow
VALUE+-
*XRequired
- Pickup Options - Card will be printed at the location shown and you can pick up within 24 hours
VALUE+-
*XRequired
Authorization
x
I, the Account Holder, hereby apply for a Combined Automated Teller Machine / Point Of Sale / Debit (ATM/POS/Debit) Card to be used in conjunction with the account(s) listed above. I understand that the card will be set up with the features and functions I have selected, and that usage of the card is subject to the terms and conditions set forth in the Deposit Account Agreement, Regulation E Disclosure, and any other applicable disclosures, which have been provided to me electronically or are available upon request. I authorize First State Bank & Trust to issue a Visa® Debit Card in my name and link it to my designated account(s). I affirm that I am the authorized account holder and agree to all terms governing the use of the card, including those related to liability for unauthorized transactions, overdrafts, and applicable fees. I also agree not to use the Combined ATM/POS/Debit Card for any illegal activity. I further authorize the Bank to make any necessary investigation of my credit, either directly or through a credit reporting agency. I understand the Bank may retain this application and any related credit or identification information, whether or not the card is issued. By checking this box, I acknowledge and accept these terms and authorize the issuance of the debit card as described above. I, the Account Holder, hereby apply for a Combined Automated Teller Machine / Point Of Sale / Debit (ATM/POS/Debit) Card to be used in conjunction with the account(s) listed above. I understand that the card will be set up with the features and functions I have selected, and that usage of the card is subject to the terms and conditions set forth in the Deposit Account Agreement, Regulation E Disclosure, and any other applicable disclosures, which have been provided to me electronically or are available upon request. I authorize First State Bank & Trust to issue a Visa® Debit Card in my name and link it to my designated account(s). I affirm that I am the authorized account holder and agree to all terms governing the use of the card, including those related to liability for unauthorized transactions, overdrafts, and applicable fees. I also agree not to use the Combined ATM/POS/Debit Card for any illegal activity. I further authorize the Bank to make any necessary investigation of my credit, either directly or through a credit reporting agency. I understand the Bank may retain this application and any related credit or identification information, whether or not the card is issued. By checking this box, I acknowledge and accept these terms and authorize the issuance of the debit card as described above.
- I have read and accept the terms above and authorize the issuance of a Visa® Debit Card.
VALUE+-
*XRequired
Deposit Agreement
x
Electronic Funds Transfer Agreement and Disclosure
x
Please type your full name below to serve as your electronic signature and confirm your agreement to the above terms. By typing my name above and submitting this application, I am electronically signing and agreeing to the terms provided above. I certify that all information submitted is true and correct.

*X Required
Today's Date

*X Required

Debit Card Application Form

Consent to Electronic Records

Information

Card Design & Pickup Options

Authorization