Visa Check Card Application

Use your "PRINT" command to get a "VISA CHECK CARD" Application---->>> Iberville Bank..."Strength-Service-Solutions"
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PLEASE READ OUR "USA PATRIOT ACT" NOTICE

PLEASE READ OUR "PRIVACY STATEMENT" BEFORE COMPLETING THIS APPLICATION

Bank Use Only

Please list your accounts that will be associated with your VISA check card.

Checking:____________________
Savings:______________________

________________________________

_________

_______________________________

First Name

Middle

Last

___________________________________________________________________________

Mother's Maiden Name

___________________________________________________________________________

Address

______________________________________________	__________	__________	__________
City	State	ZIP Code	Years at Address

(________) ____________________________	(________) ____________________________
Home Phone	Business Phone

___________________________________________________________________________

Previous Address (if less than 2 years at current address)

___________________________________________________________________________

Present Employer (if retired, list former)

Years in Business____________________ Gross Monthly Salary____________________

SS# ___ ___ ___ /___ ___ /___ ___ ___ ___	Dr Lisc #________________________
Source of Other Income	Amount	Annual	Monthly
Note: Income from alimony, child support or separate maintenance payment need not be revealed if you do not choose to disclose it as income.

Signature This information is given to obtain the Visa check card and is true and complete. I authorize you to verify the information contained on this application and to obtain further information from a consumer credit report to assist in the review process. When I, or someone I authorize, use the card, I agree to the terms and conditions of the agreement when I receive my card, I understand that the financial institution may assess service charges for the privilege of having a Visa check card. At Iberville Bank, receipt and use of a Visa check card incurs no additional fees other than usual checking account charges. If the Visa check card has no activity within 12 months of issuance date, a $12.00 annual fee will be applied. I understand if my checking account becomes overdrawn due to a Visa check card transaction an overdraft fee may be charged.
______________________________________	______________________________________
Applicant's Signature	Date

Mail to: Visa Check Card Department P O Box 695 Plaquemine, La. 70765-0695

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