Combined ATM/POS/Debit Card Request Form

(For Print Only- complete form and bring to nearest branch)

Citizens State Bank  

Woodville-Warren-Spurger-Marlin 

Request:  (Circle One:)     New Card     /     Replacement Card

If Replacement, was card lost/stolen? ________  Or was card damaged? __________

(Please note that a nominal fee may be charged for replacement cards.)

Account Holder:                                                                                       Phone:     (            )                                  

Address:                                                                                                     

                                                                                                                                             

Issue Cards to:

Name:                                                                                                       

SSN:                  -            -                  DOB:              /             /             

Name:                                                                                                       

SSN:                  -            -                  DOB:              /             /             

Mailing address (if different):                                                                                                 

                                                                                                                                                   

Account Information and Instructions:

Account(s) to access with combined ATM/POS/Debit Card:

Primary Account #:                                                                                                    

Note:  Point of Sales (POS) transactions or POS debit card transactions on the VISA network from your Combined ATM/POS/Debit card will be deducted from the Primary Account listed above.  Point of Sales (POS) transactions or POS debit card transactions involving a refund will be credited to your Primary Account.  Unless you specify a different account during Automated Teller Machine (ATM) transactions, the Primary Account will be used for your transactions.  Visa is a registered trademark of Visa International.

The Combined ATM/POS/Debit Card cards are to be setup/enabled with the following features:

Authorization

I (the Account Holder) 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.  The Combined ATM/POS/Debit Card will be setup (pursuant to my request) with the functions or features indicated above and usage of the Combined ATM/POS/Debit Card will be subject to the terms and conditions contained 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 Combined ATM/POS/Debit Card is not granted.  I agree not to use the Combined ATM/POS/Debit Card Service in any illegal activity.

Account Holder:

X________________________________________    Date: ______/______/_______

X________________________________________    Date: ______/______/_______

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For Institution Use Only                                                                                  

By:                                                     

Date Taken:                                                   

Date Approved:                                                   

Card Number Assigned:  Customer:                                                        #                                                   

Card Number Assigned:  Customer:                                                        #                                                   

Data Entry Date:                                                  By: