| Peoples
Exchange Bank Money Card Application Print
this page, complete form, and mail |
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| Peoples
Exchange Bank P.O. Box 160 Belleville, KS 66935-0160 |
Peoples
Exchange Bank P.O. Drawer 9 Clyde, KS 66938-0009 |
Peoples
Exchange Bank P.O. Box 649 Concordia, KS 66901-0649 |
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| Name of Cardholder (Last, First, MI)
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| Address: (City, State, Zip)
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| Social Security Number | Telephone Number | Date of Birth
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| Name of Cardholder (Last, First, MI)
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| Social Security Number | Date of Birth
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| This card should be linked to my checking account
for purchases at merchants, cash withdrawal and balance inquiry use. List checking
account number. (Do not list savings or money market account.) |
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| Checking
account number
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| Optional: This card should be linked to my
savings/money market account for purposes of cash withdrawal, transfer between this
account and the above checking account and balance inquiry use. List savings or
money market account number.
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| I request that you issue a Peoples Exchange Bank Money Card in the names above and that you renew and replace the card(s) until notice to the contrary is given. I promise to pay, in accordance with the Electronic Funds Transfer Disclosures I will receive upon bank's receipt of this application, all debits and fees generated by Money Card transactions on the above accounts. If this is a joint application, I agree to be jointly and severally liable for all Money Card transactions. I understand that a credit report from an outside agency may be required prior to approval of this card, and I hereby give my permission to Peoples Exchange Bank to obtain such report. I will be charged $3.00 for the report. I provide the following bank as a credit reference:
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| Bank Named for
credit reference
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Address | |
| I authorize the above bank to provide Peoples
Exchange Bank information regarding my credit and deposit experience with the banking
reference over the last five years.
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| Applicant Signature (Required) | Date | |
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| Co-Applicant Signature (Required if Joint Application) | Date
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