Page 1 of 1
Questions? Go to Fidelity.com or call 800-343-3548.
1.9862858.103 032350101
On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are
provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 707750.4.0 (06/20)
Fidelity
®
Debit Card Application
Use this form to apply for the Fidelity
®
Debit Card (“ATM/Debit Card”) for your individual, joint, or trust Fidelity Account
®
or
Fidelity
®
Cash Management Account.
Use of your ATM/Debit Card makes recordkeeping easy. ATM/Debit Card transactions are provided on your account statement. Your pur-
chases are automatically deducted from your account daily. The ATM/Debit Card is provided to you with no annual fee.
Type on screen or fill in using CAPITAL letters and black ink. If you need more room for information or signatures, make a copy of the
relevant page.
1. Account Owner(s)
Name(s) Account Number
Daytime Phone Extension
Request additional card for joint owner.
2. Signature(s) and Date(s) Form cannot be processed without signature(s) and date(s).
By signing below, you:
• Certify that you have read, and that you meet,
understand, and agree to, all the terms,
conditions, and disclosures in this section.
• Request that a Fidelity
®
Debit Card be issued
in the name of the Account Owner(s).
• Understand that the Fidelity
®
Debit Card is
issued by PNC Bank, N.A., and the debit
card program is administered by BNY Mellon
Investment Servicing Trust Company. Use of
this feature is subject to approval by PNC
Bank, N.A.
• Agree to abide by the terms and conditions
set forth in the Agreement and Disclosure
Statement governing your ATM/Debit Card,
which will be provided by PNC Bank, N.A.,
when the card(s) is (are) issued, as it may be
amended from time to time. PNC Bank, N.A.,
is not affiliated with Fidelity.
• Certify that all information you have provided
in this form is true, accurate, and complete.
• Understand that you are responsible for any
fees imposed by the bank providing ATM
access, unless your debit card is linked to
a Fidelity Cash Management Account, or
you are a Private Client Group or Premium
Services customer, or you have a household
annual trading activity of 120 or more stock,
bond, or options trades. There may be a for
-
eign transaction fee of one percent that is not
waived, which will be included in the amount
charged to your account.
PRINT OWNER/AUTHORIZED INDIVIDUAL NAME
OWNER/AUTHORIZED INDIVIDUAL SIGNATURE Date MM/DD/YYYY
SIGN
X X
PRINT OWNER/AUTHORIZED INDIVIDUAL NAME
OWNER/AUTHORIZED INDIVIDUAL SIGNATURE Date MM/DD/YYYY
SIGN
X X
Did you sign the form? Send the form to Fidelity Investments.
Questions? Go to Fidelity.com or call 800-343-3548.
Regular mail
Fidelity Investments
PO Box 770001
Cincinnati, OH 45277-0002
Overnight mail
Fidelity Investments
100 Crosby Parkway KC1K
Covington, KY 41015
This phone number may
be used if we have
questions, but will not
be used to update your
account information.
