Farmington Bank Business Debit & ATM Card Application and Agreement
FOR BANK USE ONLY
Card # ______________________________________ Card # ______________________________________ Port # _______________________
Date Approved __ __ / __ __ / __ __ __ __ Responsibility Code ______
Date Ordered __ __ / __ __ / __ __ __ __ Responsibility Code ______
Please use pen and print clearly.
Your Information
____________________________________________________________________________________________________________
Business Name
EIN #
_______________________________________________________________________________________________ __ __ __ __ __
Street Address
(
) __ __ __ - __ __ __ __
Best Phone for Contact
(
City
) __ __ __ - __ __ __ __
State
(
Secondary Phone
Zip
) __ __ __ - __ __ __ __
Business Phone
____________________________________________________________________________________________________ __ __ / __ __ / __ __ __ __
Authorized User
SSN
DOB
____________________________________________________________________________________________________ __ __ / __ __ / __ __ __ __
Authorized User
SSN
DOB
I would like to apply for the Farmington Bank:
Business Debit Card with MasterCard® Logo
The following checking account is authorized
for debit card and ATM use:
#
The following savings and/or Money Market
accounts are authorized for ATM use only:
#
#
ATM Card
Personal Identification Number (PIN):
You will receive your PIN in a separate mailing a few days after you receive your card. This number belongs to you and
is the key to the security of your accounts. Once entered into our system it is unavailable to anyone else, including bank personnel. If you forget your PIN, speak to one of our
customer service representatives about ordering a new PIN for you. To change your PIN, please go to the nearest Farmington Bank ATM and follow the directions on the screen.
Authorizations: By signing below, I am applying for a Farmington Bank Business Debit Card with MasterCard® logo or a Farmington Bank ATM card. I have read and
agree to all the terms in the attached Commercial MasterMoney Card and ATM Card Agreement. I understand this is not a credit card and that the dollar amount of purchases
made with this card will be deducted from my Farmington Bank checking account only. I authorize Farmington Bank to verify the information provided above and to request a
credit report if necessary. The Farmington Bank Business Debit Card is available for qualified customers only. Other requirements may apply.
Alternate Security Procedure (Applicable box is checked): We have offered you and you have [
] accepted [ ] declined to use a security
procedure that prohibits withdrawals from your account.
________________________________________________________________________________
__ __ / __ __ / __ __ __ __
Signature
Date
________________________________________________________________________________
__ __ / __ __ / __ __ __ __
Signature
Date
Note: Only those individuals signing above may use the Business Debit Card on any one of the designated accounts.