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First Bank Kansas
Mastercard Check Card Application

Privacy Policy:
Our privacy policy protects the privacy of your personally-identifying information that you provide us online.
The following Mastercard Check Card application is intended for use with personal checking and savings accounts only. Businesses wishing to have a Mastercard Check Card should click here to email the Commercial Services department.

Security Notice:
You should ONLY fill out this Application online if you are using a browser with the latest security enhancements. If you don't have the latest version, download a copy now.
Instructions:
1. Complete Application and click "Submit Application" or fax it to 785-825-7663.
2. To safeguard your privacy, QUIT your browser and restart it again after using this form. This form is NOT saved in your computer's memory when you quit your browser.

Primary Cardholder Information
First Name
Middle Initial
Last Name

Date of Birth
Social Security No.

Home Phone
Email Address
Mother's Maiden Name

Driver's License No.
Driver's License State
Driver's License Issue Date
Driver's License Expiration Date

Street Address
City
State
Zip
Employer
Occupation
Work Phone

Secondary Cardholder Information (if applicable)
First Name
Middle Initial
Last Name

Date of Birth
Social Security No.

Home Phone
Email Address
Mother's Maiden Name

Driver's License No.
Driver's License State
Driver's License Issue Date
Driver's License Expiration Date

Street Address
City
State
Zip
Employer
Occupation
Work Phone

I wish to access the following accounts (list all account numbers that apply)
Checking Account #

Savings Account #

By submitting this application, I (each person jointly and severally) agree that I have read and understand the terms of the Electronic Funds Transfer disclosure and the Fee Schedule. Click here to read these documents.

I/We AGREE with the above statement