Debit Card Application Form

Debit Card Application Form

Debit Card Application Form
Need a new debit card? You're in the right place. Whether you're requesting your first card or a replacement, this simple online form makes the process fast and easy.

Please Note:

If you're debit card is ever lost or stolen, contact the bank immediately and speak with Bookkeeping to ensure the card is closed and your account is protected.

Call 606.845.2461 or visit your nearest branch
Today's Date

MonthDayYear
IndividualBusiness

Applicant's Information
Please Read Before You Begin:

All required fields must be completed to successfully submit your debit card request. Once submitted, your new debit card will be mailed to the address on file. Please allow 5 - 7 business days for delivery--shipping times may vary depending on holidays and/or natural disasters.

Important: If your address has changed within the last 30 days, your application will be held until the 30 day period is complete. After that, your debit card will be ordered and mailed.

If you have you have any questions please call us at 606.845.2461 during normal business hours.

Please complete all fields with an asterisk (*)
Name*

First NameLast Name
Business Name*
Employee's Name*

First NameLast Name
PhoneE-mailOther
Business Phone Number*
Format: (000) 000-0000.
Phone Number*
Format: (000) 000-0000.
E-mail Address*
Applicant's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business' Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EIN*
Applicant SSN*
Date of Birth*

MonthDayYear
Account Number(s)*
New CardReplacement CardAdditional CardOther
Age

Parental Consent Required for Applicants Under 18

Because you're under 18, we need a parent or legal guardian's information to proceed with your debit card application.
Parent / Legal Guardian's Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Email*
Date of Birth*

MonthDayYear
SSN*

Choose your card style.

To view our various styles, click here.
Card Style*

Authorization:

By clicking the "I Accept" box below, the applicant(s) request(s) the described services and agrees to the terms and conditions governing the services, including any fees and changes. The applicatant(s) agree(s) that all information is accurate and authorizes the financial institution to verify credit and employment history, if necessary, by any means, including preparation of a credit report by a credit agency. Check the "I Accept" box to indicate that you (the applicant) have read the agreement and accept its terms.
Please verify that you are human*
Applicant's Signature

Clear
Parent/Gaurdian's Signature

Clear
Should be Empty: