Business Debit Card Application Form

Important Information About Procedures for Opening a New Account

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you:

When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

Title

Mr.Mrs.Miss.

First Name*

Middle Name

Surname*

Gender*

MaleFemale

Date of Birth*

Month Day Year

DL Number*

Social (used for verification, DOES NOT AFFECT CREDIT)*

Marital Status*

SingleMarriedDivorcedWidow(er)

Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Telephone Number (Mobile)*

Area Code Phone Number

Telephone Number (Home)

Area Code Phone Number

Email*

example@example.com

Date*

Date

Declaration:

The undersigned acknowledge that they have read and agree to the Checking/Debit Card Agreement presented on the following pages. They further agree that until this authorization is revoked in writing and received by KAPED, KAPED may charge the account of the undersigned in the amount of all checks written by authorized users, and for all authorized card transactions. This Agreement supplements the KAPED Client Agreement previously provided to the undersigned account owners. Undersigned further agree to hold harmless and to fully indemnify and defend at their own cost, expense, and risk KAPED, its affiliates, and their respective officers, employees, and agents, from any third party claim, demand, liability, loss or damage, or judgment, including costs of legal defense, which shall include attorney fees, arising out of this Agreement excluding claims for damages resulting from the gross negligence of KAPED.

By signing this Agreement, I authorize KAPED to cancel or discontinue any other checking or debit card programs on this account.

All Account Owners and legal Power of Attorneys are required to sign this Authorization. If you wish to designate an individual who is not an Account Owner as an Additional Check User, he/she is required to sign this form as well as to complete the Additional Check User form. Please note, only authorized agents with Full Trading Authorization are eligible to be an Additional Check User.

Bizzy Debit Card Agreement & Terms

Name*

First Name Last Name

Signature*

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country