Franklin Savings Bank

603.934.4445, 1.800.372.4445

Smarter Banking. Easier Living.

Visa™ Debit Card Application

Government regulations require that we make the following disclosures available to you when you apply for a new Visa Debit card with Franklin Savings Bank. Please feel free to print any of these disclosures.

It is our policy to supplement the disclosures available on our website (www.fsbnh.bank) with paper copies once the card application is processed. Upon receipt of this application, we will mail you the proper disclosures.

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

E-Mail Address:
First Name:
Middle Initial:
Last Name:
Mailing Address:
City:
State:
Zip:
Date Of Birth:
Home Phone #:
Mobile Phone #:
Work Phone #:
Mother's Maiden Name:

Co-Applicant
First Name:
Middle Initial:
Last Name:
Mailing Address:
City:
State:
Zip:
Date Of Birth:
Home Phone #:
Mobile Phone #:
Work Phone #:
Mother's Maiden Name:
Primary Checking Account #:

Secondary Account #(s) (Checking or Savings):


Desired PIN #:	1 digit per box
Please select only numbers. Only 4 characters are allowed. Please do not select all zeros.

The bank may obtain a current credit report upon receipt of this application. I also agree that the bank may mail all account disclosures to the address listed above. I agree to abide by the regulations, terms and conditions established by FSB as related to the use of the card.

I will print this application, sign it, and mail it to: Attn: Customer Service Team Franklin Savings Bank 387 Central Street Franklin, NH 03235

I will submit this form electronically and an application will be mailed to me for my signature.
Signature of Applicant:		Date:

Signature of Co-Applicant:(if applicable)		Date: