Debit MasterCard®
ATM Card
CARD REPLACEMENT FEE OF $10
CARD #1
Name to Appear on Card: ____________________________________________ CIF# ________________
Social Security No: ___________________ Date of Birth ______________ Phone#: _________________
Address: _______________________________City: __________________ State: ______ Zip: _________
Mother’s Maiden Name: _________________________ Alternate Phone#:__________________________
Signature: _____________________________________
I would like to use my card with the following account numbers:
Primary Checking: _____________________ Secondary Checking: ______________________
Primary Savings: _____________________ Secondary Savings: _______________________
For Office Use Only
Enter Date:___/___/___ By:___________ Card No:__________________________
CARD REPLACEMENT FEE OF $10
CARD # 2
Name to Appear on Card: ____________________________________________ CIF# ________________
Social Security No: ___________________ Date of Birth ______________ Phone#: _________________
Address: _______________________________City: __________________ State: ______ Zip: ________
Mother’s Maiden Name: _________________________ Alternate Phone#:__________________________
Signature: ____________________________________
I would like to use my card with the following account numbers:
Primary Checking: ____________________ Secondary Checking: _____________________
Primary Savings: _____________________ Secondary Savings: ______________________
For Office Use Only
Enter Date:___/___/___ By:___________ Card No:__________________________
I/We, the above signed, understand and agree that:
(a) All transactions entered into with this card are subject to the agreements of the account involved.
(b) I/We will make every reasonable effort to safeguard my/our card and my/our personal identification number.
(c) This agreement may be terminated at any time by either the bank or the card holder.
(d) Daily cash withdrawal and point of sale purchase limits apply to each card issued.
*Initial Limit for ATM Card: $500 Cash Withdrawal. Under 18 years of age limit is $100.
*Initial Limit for Debit MasterCard® Card: $500 Cash Withdrawal / $750 Point of Sale.
(e) When you use an ATM not owned by us, you may be charged a fee by the ATM operator [or any network used]
and you may be charged a fee by us. You may also be charged a fee for a balance inquiry even if you do not
complete a fund transfer.
Please mail completed form or drop off at your nearest branch location.