SHAZAM "QuickCHECK" APPLICATION FOR STATE BANK OF CHRISMAN

Large SHAZAM logo PARIS FIRST
600 E. Jasper St .
Paris , IL 61944
217-465-6360
STATE BANK OF CHRISMAN
202 W. Madison
Chrisman , IL 61924
217-269-2339
 

Applicant

 

SS#

 

DOB

 

Co-applicant

 

SS#

 

DOB

 

Street Address

 

Box #

 

City

 

State

 

ZIP

 

Home phone

 

Employer (applicant)

 

Work Phone

 

Employer
(Co-applicant)

 

Work Phone

 

Deduct my "Quick Check" card purchases & withdrawals from checking account #

 

If my "Quick Check" card is damaged, lost or stolen, I/we may be required to pay a replacement fee$10.00 (ten dollars).

By signing the application, I/we authorize a consumer credit report and verify the statements in this application. Furthermore,I/we agree to be bound by the terms and conditions of the debit card including any fees and charges and the electronic fund transfer brochure, copies of which will be mailed to the applicant(s) if a card is granted. Receipt of terms and conditions, and disclosure, and acceptance of such terms will be
conclusively presumed by the use of the card. If this is a joint account, the undersigned shall be jointly and severally liable for any and all debit card transactions. BOTH parties must sign if a joint checking account is involved.

Applicant signature:   Date:  
Co-applicant signature:   Date: