Liberty Bank

 

Shazam Application

 

If you have any questions regarding this application, please call 1-217-645-3434 and ask for Customer Service.

APPLICATION FOR: (choose ONE)

SHAZAMCHEK CARD

SHAZAM ATM CARD

Primary Cardholder

Secondary Cardholder (if applicable)

Last Name

Last Name

First Name

First Name

MI

MI

Social Security #

- -

Social Security #

- -

Birth Date

/ /

Birth Date

/ /

Street Address

 

 

Mailing Address (If Different)

 

 

City

 

 

State

 

 

Zip Code

-

 

 

Home Phone

( ) -

 

 

Work Phone

( ) -

 

 

FBL Checking Account Number:

- -

DAILY LIMITS REQUESTED:(if other than amt shown: Daily Max includes POS purchases And ATM withdrawals)

Daily Max ($200.00)

$

ATM-only ($200.00)

$

3-day Max ($500.00)

$

 

 
 
 
 

Primary Cardholder Signature

Date

Secondary Cardholder Signature

Date

FOR BANK USE ONLY:

Date Account Opened

Rush (Extra Chg):

Yes No

Avg. Bal. Maintained

Date Ordered:

NSF Items in last 12 months

Expiration Date:

Other ACCTS: (IL) (CL) (RE) (SAV) (CD) (SDB)

Reissue Months:

Limits
(If other than 200/200/500)

/ /

Date Activated:

Approved/Rejected by

Date:

Card No. Issued: _________ _-_ _ _-_ _ _
OR ______ _ _ _ _ _ _ _ _ _ _

Please complete this application, print, sign, date, and visit your nearest branch or stop in and see us at:

LIBERTY BANK
1002 North Main
Liberty, IL 62347

Barry Community
Banking Center
PO Box 132
Barry, IL 62312

Payson Community Banking Center
402 West State Street
Payson, IL 62360

Quincy Community
Banking Center
4134 Broadway Street
Quincy, IL 62305

Liberty Bank
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