Debit Card Application

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Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Social Security Number*

Date of Birth*

Checking Account Number*

Savings Account Number*

I understand that I am the only individual authorized to use the card and that use of the card signifies agreement to the terms and conditions set forth in Heritage Bank’s Electronic Funds Transfer Disclosure, which I will receive again with my new Debit Card. I authorize the bank to make inquiries to the credit bureau and verify all information on this application to underwrite this Debit Card request.

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