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Request for Visa Check Card

Please Print or Type the information below:

IMPORTANT:  All of the fields below, with the exception of those marked "OPTIONAL",are required for Danville State Savings Bank to order your new debit card.

______________________________________________________________________________
Last Name                     First Name                   MI                     Soc. Sec. No.               Birth Date

^{(Primary Card Holder)}

______________________________________________________________________________
Last Name                     First Name                   MI                     Soc. Sec. No.               Birth Date

^{OPTIONAL(Secondary Card Holder)}

______________________________________________________________________________
Home Address

______________________________________________________________________________
City                                                   State                                                       Zip

(______)___________________________________(______)____________________________
Phone Number                                                               Alternate Phone Number

This card should be linked to my Checking account number for VISA purchases and ATM use:

(REQUIRED)     Checking account number __________________________

This card should be linked to my Savings account number for ATM access only:

(OPTIONAL)     Savings account number __________________________

______________________________________ ______________________________________
Primary Cardholder Signature                            Date               Secondary Cardholder Signature                            Date

Our default card setup is: $205.00 daily cash withdrawal limit, $1,000.00 daily purchase limit, and $2,515.00 3-day purchase limit. These limits can be adjusted with the approval of a bank officer.

If you have questions about our Debit cards or need assistance in using this form, please call (319) 392 - 4261 or toll-free (877) 392 - 4261

Please mail completed form to:
                            Danville State Savings Bank
                            109 N. Main St.
                            Danville, IA 52623

or FAX to (319) 392-4660

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