Mastercard Debit Card Application
Submitter Information (Required)
First Name (required)
Last Name (required)
Resolve the errors marked in red before submitting again.

Privacy Policy:
Our privacy policy protects the privacy of your personally-identifying information that you provide us online.


Applicants must reside in Kansas.

Important Information about Procedures for Opening a New Account
Identification Procedures Requirements: To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

Security Notice:
You should ONLY fill out this form on-line if you are using a browser with the latest security enhancements. If you don't have the latest version, download a copy now. This form is NOT cached (saved in your computer's memory) when you QUIT your browser.


Instructions:
1. Complete application on-line and click "Submit Application" or fax it to 785.825.7663. Alternatively, you can print the completed application and bring it to a First Bank Kansas location
2. To safeguard your privacy, QUIT your browser and restart it again after using this form.

 

Card Card Request
Type of Application:
Primary Cardholder Information
First NameMiddle InitialLast Name
Date of BirthSocial Security No.
Driver's License No.Driver's License StateDriver's License Issue DateDriver's License Expiration Date
Home PhoneEmail AddressMother's Maiden Name
Street AddressCityStateZip
EmployerOccupationWork Phone
Secondary Cardholder Information (if applicable)
First NameMiddle InitialLast Name
Date of BirthSocial Security No.
Driver's License No.Driver's License StateDriver's License Issue DateDriver's License Expiration Date
Home PhoneEmail AddressMother's Maiden Name
Street AddressCityStateZip
EmployerOccupationWork Phone
I wish to access the following accounts (list all account numbers that apply)
Checking Account #Savings Account #
Applicant(s) Statement

By submitting this application, I (each person jointly and severally) agree that I have read and understand the terms of the Electronic Funds Transfer disclosure and the Fee Schedule. Click Here to read these documents. 

I/We AGREE with the above statement