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DEBIT CARD APPLICATION
Attention:  Fill in all the information, print the form on your printer, and then fax it or mail to:
Kentland Bank
P.O. Box 145
Kentland, IN 47951
219-474-5155
Fax 219-474-5071		 Lake Village
P.O. Box 245
Lake Village, IN 46349
219-992-3313
Fax 219-992-2501		 Rensselaer
P.O. Box 164
Rensselaer, IN 47978
219-866-4142
Fax 219-866-4514		 Roselawn:
P.O. Box 304
Roselawn, IN 46372
219-345-4646
Fax 219-345-2038
Primary Cardholder Information:
Checking Account Number  
First Name  
Last Name  
e-mail Address  
Street Address  
City,

State

 ,
 
Zip-Plus 4 -
Social Security #  
Date of Birth (mm/dd/yy)  
Home Phone Number  -
Employer  
Are you a U.S. citizen?  yes     no
Secondary Cardholder Information:
Please issue an additional card in the name of:
Checking Account Number  
First Name  
Last Name  
e-mail Address  
Street Address  
City,

State

 ,
 
Zip-Plus 4 -
Social Security #  
Date of Birth (mm/dd/yy)  
Home Phone Number  -
Employer  
Are you a U.S. citizen?  yes     no
I/we agree that the use of any Debit Card ("Card") issued in response to this application will constitute my/our agreement to be jointly and separately bound by the terms and conditions of the Debit Card Agreement delivered with the Card. I/we certify that the above information is complete and true, and is provided for the sole purpose of obtaining the Card(s). I/we authorize Kentland Bank to make whatever credit and/or investigative inquires deemed necessary in connection with this application. I/we understand that this Card is not a Credit Card, and that no commitment to extend credit to me (us) will be made by your issuance of the Check Card(s) requested.
 I (We) acknowledge and agree to the terms and conditions as outlined above.
 
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