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Debit ATM Application

Village Bank Debit/ATM Card Application
Please print this form, fill it out and fax to 763-753-6002
General Information
Will there be a co-applicant on this application? emptycheckbox Yes emptycheckbox No
I am interested in:
emptycheckbox ATM Card Only
emptycheckbox ATM and Check/Debit Card
Primary Applicant:
Account Number: Checking Account Number:
How your name should appear on card
Last Name: Middle Name:
First Name: Social Security Number (TIN):
Date of Birth: Home Phone Number:
Work Phone Number: Other Phone Number:
Email Address: Drivers License #:
Drivers License State: Mother’s Maiden Name:
Present Employer Name:
Home Address
Address 1:
Address 2:
City: State, Zip:
Co-Applicant:
Last Name: Account Number
First Name: Middle Name:
Social Security Number (TIN): Date of Birth:
Home Phone Number: Work Phone Number:
Other Phone Number: Email Address:
Drivers License #: Drivers License State:
Mother’s Maiden Name: Present Employer Name:
Home Address
Address 1:
Address 2:
City: State, Zip:
Additional Information
How would you prefer to be contacted?
emptycheckbox Home Phone
emptycheckbox Work Phone
emptycheckbox Other Phone
emptycheckbox Email Address
emptycheckbox Other:
Special Instructions/Comments:


Signatures
Primary Applicant Signature: Date:
Co-Applicant Signature: Date: