SHAZAMChek Application Form
Please compete and return to Citizens State Bank via mail or fax to 712-335-4603.
Name:
Address:
City, State, Zip:
Home Phone:
Work Phone:
Social Security Number:
Date of Birth:
Checking Account#:
Savings Account #:
Joint Owner Name:
Joint Owner Social Security Number:
Joint Owner Date of Birth:
I (We) agree that the bank may rely on the accuracy for the above information to obtain and/or verify my (our) credit history, bank references, employment, and any other information permitted by law to determine my (our) credit worthiness.
If my SHAZAMChek card is damaged, lost or stolen, I (We) will be required to pay a replacement fee of $10.00 per card.
I understand there is a charge of $1.00 per month to have a SHAZAMChek card.
Signature:__________________________
Date:__________________________
Signature of Joint Applicant:__________________________
Date:__________________________
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