Apply for a Visa Debit Card

In order to apply for a Visa Debit Card you must be an owner of the checking account. Please complete the form below. If your card has been lost or stolen, or if you have any questions about completing the application, please call our service center at (785) 275-5009.

Required Field

General

Card Type *You will need to contact your local branch for applicable Instant Issue card fees. Please see Instant Issue card designsand specify which design you would like. Instant Issue Card Design

Applicant

First Name Middle Initial Last Name Suffix Physical Address City State Zip Code Mailing address is different than street address. Physical Address Social Security Number Birth Date Mother's Maiden Name Home Phone Number Cell Phone Number Business Phone Number E-mail Address Please do NOT email me important news and updates.

How would you prefer to be contacted?

Home Phone
Cell Phone
Business Phone

Accounts to be accessed

Checking # Savings #

Date

Authorization

By clicking the "I Agree" box below, I understand that I am accepting responsibility for all card transactions which are made by any of the undersigned or by anyone who has been given permission by any of the undersigned. I have received a copy of this form, a Regulation E Disclosure, and the bank's current service charge schedule for the ATM/Debit transactions.

The information is true and complete. I request that you issue a Visa Debit card in the name shown above. I authorize you to investigate my credit and to report to others on your credit experience with me. I promise to pay, in accordance with the current Debit card Customer Agreement, all debits, fees and extensions of credit generated by usage of the card(s).

I understand that any card issued under this Agreement is the property of The Citizens National Bank (the "Bank"). The Bank may terminate this Agreement or cancel the card(s) issued to any of the undersigned without notice at any time and for any reason in its sole discretion. Without limiting the foregoing, the Bank may terminate the card(s) immediately if: (1) a Customer breaches this or any other agreement with the Bank; (2) the Bank has reason to believe that there has been or may be an unauthorized use of a Customer's account, card, or PIN; or (3) the Bank determines, in its sole discretion, that it will not be able to collect all amounts due to the Bank under any checking account, savings account, or consumer and/or commercial loan associated with the Customer. Termination of this Agreement or cancellation of any card(s) issued under this Agreement will not affect a Customer's liability for any present or future transactions or charges resulting from the use of the card(s) by any of the undersigned or by anyone who has been given permission by any of the undersigned.

Yes, I agree.

Assinged Card # (Internal Use Only)