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Yes! I want a First CheckCard!
Print & fill out Form. Mail, fax or drop off at any FSCB location.
Click here for address and fax information.


 
Last Name (Primary Card Holder) First Name MI Social Security No. Birthdate
If Primary Card Holder is a minor (16 or 17 years old) please indicate here Minor Adult
     Note: Minors are required to have a parent's/guardian's signature on this application. The name must match the adult's signature on the account.
Will the adult want a second debit card to be issued on his/her name? Yes No


 
Street Address (Current Residence)City, State, Zip Code
Home Phone Number    

 

 

        
Primary Card Holder Employer Name, Address & Phone Number    

 

 

        
Last Name (Secondary Card Holder) First Name MI Social Security No. Birthdate


 
Secondary Card Holder Employer Name, Address & Phone Number

 
   
Initial Here ______ Link this card to my checking account # _______________ for purchases and ATM use.
Initial Here ______ Link this card to my saving account # _______________ for ATM access only.
        The above information is submitted for the purpose of obtaining a First State Community Bank First CheckCard (Card) and is certified to be true and correct. I authorize First State Community Bank with whom the deposit accounts designated above are on deposit (Bank) to make whatever inquiries, credit or otherwise, that the Bank feels necessary to evaluate my application. I agree that this application shall remain the property of the Bank whether or not the Card is issued, I acknowledge and agree that I will be deemed to be in agreement with all the terms and conditions contained in this application and the First State Community Bank Card holder agreement/disclosure statement to be sent to me with the Card and any future amendments of said agreement. I agree to be liable for all transactions of any kind performed by anyone to whom I entrust my Card.
        I understand if my Card is damaged, lost or stolen, I may be required to pay a PIN number replacement fee of $5.00. I authorize the Bank to issue a Card to access my account(s) and/or to make such Card service charge, as indicated above.


Primary Card Holder Signature Secondary Card Holder Signature Today's Date


Parent/Guardian Signature for Minor Card Holder
Today's Date
For Office Use Only             Officer's Initials______           Date _____________