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Debit Card Application

Applicant Information

Full Name *

Street Address *

PO Box/Apt #

City, State, Zip *

Phone Number *

Card Information

Choose One Option Below *

New Card**

Replacement Card

**a signature may be required for New Debit Card applicants

Reason for application *

Card Lost

Card Damaged

Potential Fraud/Fraud

Initial Request

There is a $10.00 fee for any lost or damaged debit cards. If you suspect fraudulent use of your debit card, please call Glasford Bank at 309-389-2551 or the number on the back of your card immediately.

Account Information

One checking and/or one savings account can be tied to a debit card. Debit cards with only a savings account tied to them will function as ATM cards and can only be used to withdraw money at an ATM.

Which account(s) should be tied to this debit card? *

Submitting this form will constitute an agreement that the use of the card will be governed by our Electronic Funds Transfer Service Agreement.

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Math question * 7 + 12 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.