Application for SHAZAM_®Card

Please print and fill out this application and mail it to us at:
First State Bank
215 North Division, P.O. BOX 400
Stuart, Iowa 50250

Application for:
I'd like to apply for the following card(s):

SHAZAM_®Card

SHAZAM_®Chek Card

Applicant

Account Number(s) _________________________

Name ______________________________________

Address ___________________________________

City ______________________________________

State ____________ Zip ____________________

Home Phone Number _________________________

Social Security Number ____________________

Date of Birth _____________________________

Employer __________________________________

Co-Applicant

Name ______________________________________

Address (if different) ____________________

City ______________________________________

State ____________ Zip ____________________

Home Phone Number _________________________

Social Security Number ____________________

Date of Birth _____________________________

Employer __________________________________

Signatures: By signing below, the undersigned request(s) the described services and agrees to the terms and conditions governing the services, including any fees and charges. The undersigned agree(s) that all information is accurate and authorizes the financial institution to verify credit and employment history by any necessary means, including preparation of a credit report by a credit reporting agency.

Applicant's Signature _____________________

Date ______________________________________

Co-Applicant's Signature _____________________

Date ______________________________________

Official Use Only

Date Received ______________

Approved (Y/N) ______________

Processed By ________________

PRIVACY POLICY   ●   SECURITY STATEMENT

© 2002 First State Bank - All rights reserved.