Union State Bank

VISA Check Card Application

Please print this page and fill out the application. If you have any questions call 785-632-3122

Please fill in your primary Union State Bank Checking Account Number.
__ __ __ - __ __ __ - __

Name: _________________________________________
First Middle Last

Address:

Street: _______________________________________

City: _________________________________________

State: ____________________ Zip: ________________

Phone#'s

Home: ___________________

Work: ____________________

Cell: ____________________

Security Info:

SSN (Last 4 digits ): ___________________

Birthdate: ___________________

Previous Bank or Credit References: ______________________

_______________________________________________________

Indicate any other Union State Bank accounts that you want to be able to access at ATMs with this card:

Checking ____________________

Savings _____________________

Each joint owner on an account must complete and sign
a separate application if multiple cards are desired.

I ("Applicant") am applying to Union State Bank ("Issuer")for a Union State Bank
VISA Check Card ("USB VISA Check Card") to be used to access and initiate
electronic funds transfers from the checking account identified above at ATM's
and participating VISA Merchants everywhere. If this application for a USB VISA
Check Card is accepted and a card issued, I will be deemed to be in agreement
with the terms and conditions accompanying the card. By signing this form, I
certify the information given herein to be true and correct. I authorize the Issuer
to verify my credit history and to answer questions about Issuer's experience
with me. I understand that the issuer will retain this application whether or not it
is approved, and that the issuance of a USB VISA Check Card is contingent
upon my credit check.

If a USB VISA Check Card is issued, I hereby authorize the Bank identified in this
application to debit the checking account identified in this application for each purchase
and cash withdrawal associated with my USB VISA Check Card.

This authorization may be terminated by either party by written notification provided to
the other party. The Bank may terminate the card for misuse, fraud, or inactivity. I
understand that I will be responsible for any authorized transactions made on my USB
VISA Check Card prior to any termination, even though such transaction may not have
been debited or posted to my account(s) as of the date of termination.

Applicant's Signature ___________________________ Date __________