ATM CARD
APPLICATION

Name _____________________________________________________________

Street Address _____________________________________________________

Apartment No. / P.O. Box No. _________________________________________

City, State, Zip Code ________________________________________________

Day Telephone _____________________________________________________

Evening Telephone __________________________________________________

Number of Cards
I request    c One Card    c Two Cards   (Check only one option)

**Please note that a PIN number will be mailed to you 3-5 days after you receive your card.**

Applicant's Driver's License # _________________________________________
Have you lived in PA for the last 5 years   c yes    c no      

If not, where? _____________________________________________________

Account Information

TYPE
ACCOUNT NUMBER
TYPE
ACCOUNT NUMBER
Checking
101
0 | 0 |   |   |   |   |   | 0 | 7 |
Checking
102
0 | 0 |   |   |   |   |   | 0 | 7 |

Statement
Savings
201

0|0|0|0|0|   |   |   |   |   |0|1|
Statement
Savings
202
0|0|0|0|0|   |   |   |   |   |0|1|
Signature(s) Required
I/We hereby acknowledge that I/We have received a copy of your ATM CARD Cardholder Agreement and that I/We have read, understand and agree to be legally bound by the terms and conditions of such Agreement. I/We also acknowledge receipt of the disclosure statement informing me/us of my/our rights under the Electronic Disclosure Act.
x_____________________________________________________________________________
Applicant's Signature                                                        Date
x_____________________________________________________________________________
Joint Applicant's Signature                                                        Date
 
Financial Institution Use Only
Special Handling
c (P) Pull Card
c (D) Demo Card

Participant Id
5 | 8 | 3 | 6 | 1 | 4

Prepared By             Date

 

Branch ID

 

 Card Prefix
5 | 8 | 3 | 6 | 1 | 4 | 0 | 0

Approved By             Date