Fillable Printable Debit Card Application Form - America

Debit Card Application Form - America

AMERICAN SAVINGS BANK

SHAZAMChek Debit Card

Application Form

(PLEASE PRINT ALL INFORMATION BELOW)

CARDHOLDER INFORMATION: ADDITIONAL CARDHOLDER INFORMATION:

Full Name ________________________________ Full Name _________________________________

Home Address ____________________________ Home Address _____________________________

P.O. Box ____________________________ P.O. Box _____________________________

City _____________________________________ City ______________________________________

State _______________ Zip Code _____________ State ________________ Zip Code _____________

Home Phone ______________________________ Home Phone _______________________________

Cell Phone _______________________________ Cell Phone ________________________________

Work Phone _____________________ext.______ Work Phone _____________________ext._______

Email __________________________________ Email ____________________________________

Social Security Number_____________________ Social Security Number ______________________

Birth Date ________________________________ Birth Date _________________________________

□ Link card to my checking account number for SHAZAMChek purchases and ATM use:

Checking account number: ______________________________

□ Link card to my savings account number for ATM access only:

Savings account number (optional): ______________________________

AUTHORIZATION

I/We apply for a SHAZAMChek debit card to be used in conjunction with the account listed above. I/We agree

that use of the SHAZAMChek card will be subject to the terms and conditions contained in the Deposit Account

Agreement and Disclosure and the electronic funds disclosure that have been provided to me/us. I/We authorize

American Savings Bank to obtain a consumer credit report and to verify statements made in this application.

_________________________________________ __________________________________________

Cardholder Signature Date Additional Cardholder Signature Date

AMERICAN SAVINGS BANK USE ONLY:

Date Received __________________ Daily Limits _______________________

# of Cards Issued __________________ Officer _______________________

Expiration Date __________________ PIN REF# _______________________