Originator Information

Additional Information if Beneficiary is Not an Established Customer and Proceeds are Delivered in Person

Beneficiary Information

Originator Authorization

By submitting this application, I/we authorize a consumer credit report and verify the statements in this application. Furthermore, I/we agree to be bound by the terms and conditions of the debit card, and the electronic funds transfer disclosure, copies of which will be mailed to the applicant if a card is granted. Receipt of terms and conditions, and disclosure, and acceptance of such terms will be conclusively presumed by use of the card. If this is a joint application, the undersigned shall be jointly and severally liable for any and all debit card transactions. Both parties must sign if a joint account is desired.