Lake Shore Savings Bank ATM/Debit Card Application
Employee requesting card ______________________ Branch #_____ Date________
Customer Name _____________________________________
Social Security Number ___________________________________
Address _______________________________________________
City, State, Zip Code _____________________________________
Type of Card Requested
572872 ATM Card Checking/Statement Savings Account number ______________________
540317 Debit Card Checking Account Number _____________________________________
519492 HSA Card HSA Account Number _________________________________________
New Order Reorder (reason) _________________ Replacement Fee Collected at Branch
(Debit and HSA card PIN can be selected at the time of card activation through the IVR system 1-800-992-3808)
PIN requested for ATM Cards only _____ _____ _____ _____
I have reviewed the ATM/DEBIT card application and agree that the above information is correct:
X _________________________________________________
Customer Signature (Required to process the order)
Customer Overdraft Services for Debit Card
Opt in Opt Out
(Overdraft Services Consent Form must be completed or on file)
Comments or other mailing instructions:
Card has been issued at branch. Employee Initials ___________
Card Number: ______________________________________