The Farmers Bank of Liberty
shazam

 

Shazam Application

 

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

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

Please complete this application, print, sign, date, and send to:

Click for FBL Home Page

The FARMERS BANK of Liberty
900 North Main
Liberty, IL 62347

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 ______ _ _ _ _ _ _ _ _ _ _