SHAZAMChek® Debit MasterCard Application

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*Name (First M. Last):
*Social Security Number:
*Date of Birth (mm/dd/yyyy):
*Address:
*City, State Zip:	,
*Primary Phone Number:
Secondary Phone Number:
Work Phone Number:
*Checking Account Number: (for purchases and ATM access)
Savings Account Number: (for ATM access only)
Would you want to select your own customized PIN?:	Yes

I request First National Bank in Pinckneyville to issue a SHAZAMChek MasterCard to the Applicant above. Please refer to the ELECTRONIC FUNDS TRANSFER AGREEMENT AND DISCLOSURES for all fees and charges applicable to First National Bank's ShazamChek Debit/ATM card.

There is no charge to use ATM machines owned by us. For ATMs not owned by us the following fees apply: A $1.00 charge for each ATM withdrawal at machines we do not own; a $1.00 charge for each ATM inquiry at machines we do not own; a $1.00 charge to transfer funds between your checking or savings at ATMs we do not own.

If my SHAZAMChek card is damaged, lost, or stolen, I may be required to pay a replacement fee. I understand that I will be billed a monthly fee of $1.00 for my SHAZAMChek card.

Your card will arrive in approximately two weeks. If you chose to select your own customized Personal Identification Number you will receive instructions to do so within seven days. If you chose not to customize your PIN you will receive a random PIN within three days after receiving your card.

* I acknowledge and agree to the terms and conditions as outlined above.

* indicates a required field

The field below helps prevent automated access. Please enter the code as it is shown in order to submit your Debit Card Application.