Debit Card Application - Bank of Zachary

To begin the process of stopping a payment on a check please complete the fields below. A member of the Bank of Zachary team will get back to you promptly to complete the process.

Personal Information

* Required Fields

First Name *

Middle Initial

Last Name *

Suffix

Date of Birth *

Last 4 Digits of SS# *

Address *

APT/Unit #

City/Town *

State *

Zip Code *

Email *

Day Phone *

Best time to call? Morning Afternoon

Account Information

Last 4 Digits of Account Number *

Last 4 Digits of Account Number

E-Sign Act Disclosure

The Electronic Signatures in Global and National Commerce Act (E-Sign Act) requires your approval before we can present disclosures electronically. You must consent to receive electronically the Electronic Funds Disclosure before proceeding with opening a Debit or ATM card and/or establishing telephone transfer service. By clicking the check box at the bottom of this page, you are consenting to receiving these disclosures electronically for this request. Your consent pertains to this transaction only and does not include any other disclosures the bank may need to provide you.

Please know that you do have the right to receive a paper version of these disclosures and may contact us by email to request a paper copy. There is no charge for a paper copy. If you do not want to consent to electronically receiving the Electronic Funds Disclosure, you should exit this form. Instead visit one of our branch offices to open our new electronic service.

To access the required disclosures, you need a Pentium-class Windows or Macintosh based PC with 256 MB of memory. The disclosure can be viewed using Adobe Acrobat Reader, which you can get for free by visiting www.adobe.com. Access to a printer or the ability to download information is necessary to obtain copies for your records.

Electronic Funds Disclosures

Please review the Electronic Funds Disclosure, which contains important policies and information pertaining to our Electronic Funds Transfer Policy.

! You must read the Electronic Funds Disclosure in order to continue.

By checking the box, I (1) am providing the 'written signature' to establish electronic services with Bank of Zachary (2) read and agree to the terms and conditions of the E-sign Disclosure and Electronic Funds Disclosure, which I consent to receive electronically (3) authorize the bank to verify employment, credit, or other information relating to my Debit card or ATM card or Telephone Transfer Service.

By checking this box I understand that information sent through this form is neither encrypted nor secure. Time sensitive requests or private information such as full account numbers and full social security numbers should not be sent online.