Member FDIC  |  Equal Housing Lender

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

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

Applicants must be current First Independence Bank customers.

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.

1. Print this Debit/ATM Card application and gather the information you'll need.
2. Complete application on-line and click "Submit Application".
3. To safeguard your privacy, QUIT your browser and restart it again after using this form.

This card application is for personal cards only and is NOT intended for commercial use. A valid social security number is required to apply. Please review and gather the information you will need before completing this form.

Debit/ATM Card Request
Im applying for a (required)
First NameMiddle InitialLast Name

Date of BirthSocial Security No.Your E-mail Address

Current Debit/ATM Card Number:
Mothers Maiden Name: (required)
Driver's License/State ID No.Driver's License/State ID StateExperation Date

Home or Cell Phone is required
Home PhoneCell PhoneWork Phone

Account Information
Debit Cards issued for Checking accounts only and you must be a current customer of the bank.
Checking (DDA)Savings (SAV)
Account Number
Reason for replacement card: (required)
Delivery Method
Residence (Must match current address on file with FIB)
Present Address (required)
Delivery Address

I am applying for an ATM/Debit Card to be used in conjunction with the accounts listed above. I agree that the use of the ATM/Debit Card will be subject to the terms and conditions contained in the Deposit Account Agreement and Disclosure and/or Regulation E Disclosure that have been provided to me. I understand that replacement cards could be subject to a $5 fee. I authorize First Independence Bank to make any investigation of my credit, either directly or through any agency. I understand that First Independence Bank will retain this application and any other credit information, even if this ATM/Debit Card is not granted.