Contact us: 877-547-9632 Long Distance

VISA CHECK CARD


Please print this page and fill out the application. If you have any questions call 785-632-3122


Please fill in your primary Union State Bank Checking Account Number.
____ ____ ____ - ____ ____ ____ - ____


Name: ________________________________________________________
                                             First              Middle              Last

Address:

Street: _______________________________________

City: _________________________________________

State: ____________________ Zip: ________________

Phone#'s

Home: ___________________

Work: ____________________

Cell: ____________________

Security Info:

SSN (Last 4 digits ):___________________

Birthdate: ___________________

Previous Bank or Credit References: _____________________________________

__________________________________________________________________


Indicate any other Union State Bank accounts that you want to be able to access at ATMs with this card:

Checking: __________________________

Savings: ___________________________


Each joint owner on an account must complete and sign a separate application if multiple cards are desired.


I ("Applicant") am applying to Union State Bank ("Issuer")for a Union State Bank VISA Check Card ("USB VISA Check Card") to be used to access and initiate electronic funds transfers from the checking account identified above at ATM's and participating VISA Merchants everywhere. If this application for a USB VISA Check Card is accepted and a card issued, I will be deemed to be in agreement with the terms and conditions accompanying the card. By signing this form, I certify the information given herein to be true and correct. I authorize the Issuer to verify my credit history and to answer questions about Issuer's experience with me. I understand that the issuer will retain this application whether or not it is approved, and that the issuance of a USB VISA Check Card is contingent upon my credit check.


If a USB VISA Check Card is issued, I hereby authorize the Bank identified in this application to debit the checking account identified in this application for each purchase and cash withdrawal associated with my USB VISA Check Card.


This authorization may be terminated by either party by written notification provided to the other party. The Bank may terminate the card for misuse, fraud, or inactivity. I understand that I will be responsible for any authorized transactions made on my USB VISA Check Card prior to any termination, even though such transaction may not have been debited or posted to my account(s) as of the date of termination.


Applicant's Signature _________________________________________________ Date ________________

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