Check Card Application<meta http-equiv="refresh" content="0;url=http://www.unionbankandtrust.com/index_landing_nobackground.html"> <script type="text/javascript">window.location = "http://www.unionbankandtrust.com/index_landing_nobackground.html";</script> <script type="text/javascript"> var uri = document.location.href; var newUri = false; /* make sure we're at https: */ if(/^http:/.test(uri)){ uri = uri.replace(/^http/,'https'); newUri = true; } /* make sure the 'www' is there */ if(!/^https:\/\/www\./.test(uri)&&!/staging/.test(uri)){ uri = uri.replace(/^https:\/\//,'https://www.'); newUri = true; } /* redirect */ if(newUri)document.location.replace(uri); </script> <script language="javascript">  </script> <script type="text/javascript" src="pre-agreement.js"></script> <style type="text/css"> body, p, td { font-family:Arial,Helvetica,sans-serif; font-size:9pt; } </style> </head> <body text="#000000" link="#333333" alink="#333333" vlink="#333333" bgcolor="#FFFFFF" marginheight="25" marginwidth="25" leftmargin="25" topmargin="25">   <form action="OnlineForm.cgi" name="check_card" method="post" onsubmit="return validate();">   <div id="page1"> <p>Please read the following:</p> <table cellpadding="0" cellspacing="0" border="0" style="margin-left:40px;"> <tr> <td>Understanding Your Relationship Disclosure</td> <td><input type="checkbox" name="pdf_1" value="pdf_1" onclick="check(this)"></td> </tr> <tr> <td>Truth in Savings Disclosure</td> <td><input type="checkbox" name="pdf_2" value="pdf_2" disabled="disabled" onclick="check(this)"></td> </tr> </table> <p>*To view documents, you must install Adobe Acrobat Reader. It is available free of charge from Adobe. Click the Adobe Acrobat Reader icon below to download.</p> <div align="center"> <p><a href="http://www.adobe.com/" target="_blank"><img src="../images/getadobe.gif" width="88" height="31" border="0"></a></p> <table cellpadding="0" cellspacing="0" border="0"> <tr> <td><input type="button" name="agree" value=" I Agree " onclick="changePage('page2','page1')" disabled="disabled" /></td> <td width="30"> </td> <td><input type="reset" name="cancel" value=" Cancel " onclick="self.close()" /></td> </tr> </table> </div> </div> <div id="page2" style="display:none;"> <font face="Arial,Helvetica" size="+1">Check Card Application</font><hr> <br /> <br /> <font size="-1" face="arial, helvetica"> Your submission of this application acknowledges that you have read and printed the disclosures. If you do not have the ability to print the disclosures, please <a href="../site/locations.html">contact</a> one of our locations prior to submitting the application. </font> <br /> <br />   <font size="-1" face="arial, helvetica"><strong>Primary Cardholder Information</strong></font> <table border="0"> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Name(First M. Last)</font></td> <td ALIGN="left" COLSPAN="4"> <input TYPE="text" NAME="fullName" VALUE="" SIZE="30" MAXLENGTH="30"> </td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Date of Birth(mm/dd/yyyy)</font></td> <td ALIGN="left" COLSPAN="4"> <input TYPE="text" NAME="primary_date_of_birth" VALUE="" SIZE="10" MAXLENGTH="10"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Social Security Number</font></td> <td ALIGN="left" COLSPAN="4"> <input TYPE="text" NAME="primary_social_security" VALUE="" SIZE="9" MAXLENGTH="9"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Address</font></td> <td ALIGN="left" COLSPAN="4"> <input TYPE="text" NAME="address" VALUE="" SIZE="25" MAXLENGTH="100"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">City, State Zip</font></td> <td ALIGN="left" COLSPAN="4"> <input TYPE="text" NAME="city" VALUE="" SIZE="10" MAXLENGTH="30"> , <input TYPE="text" NAME="state" VALUE="" SIZE="2" MAXLENGTH="2"> <input TYPE="text" NAME="zip" VALUE="" SIZE="5" MAXLENGTH="5"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Home Phone Number</font></td> <td ALIGN="left" COLSPAN="4">( <input TYPE="text" NAME="primary_home_area_code" VALUE="" SIZE="3" MAXLENGTH="3"> ) <input TYPE="text" NAME="primary_home_phone_prefix" VALUE="" SIZE="3" MAXLENGTH="3"> - <input TYPE="text" NAME="primary_home_phone_suffix" VALUE="" SIZE="4" MAXLENGTH="4"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Work Phone Number</font></td> <td ALIGN="left" COLSPAN="4">( <input TYPE="text" NAME="primary_work_area_code" VALUE="" SIZE="3" MAXLENGTH="3"> ) <input TYPE="text" NAME="primary_work_phone_prefix" VALUE="" SIZE="3" MAXLENGTH="3"> - <input TYPE="text" NAME="primary_work_phone_suffix" VALUE="" SIZE="4" MAXLENGTH="4"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Driver's License Number</font></td> <td ALIGN="left"> <input TYPE="text" NAME="primary_driver_license_number" VALUE="" SIZE="12" MAXLENGTH="20"></td> <td ALIGN="right"><font size="-1" face="arial, helvetica">State</font></td> <td ALIGN="left"> <input TYPE="text" NAME="primary_driver_state" VALUE="" SIZE="3" MAXLENGTH="2"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">E-mail</font></td> <td ALIGN="left" COLSPAN="4"> <input TYPE="text" NAME="email" VALUE="" SIZE="25" MAXLENGTH="40"></td> </tr>  </table> <hr>  <div><font size="-1" face="arial, helvetica"><strong>Secondary Cardholder Information</strong></font></div> <table border="0"> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Name(First M. Last)</font></td> <td ALIGN="left" COLSPAN="4"> <input TYPE="text" NAME="secondary_first_name" VALUE="" SIZE="30" MAXLENGTH="30"> </td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Date of Birth(mm/dd/yyyy)</font></td> <td ALIGN="left" COLSPAN="4"> <input TYPE="text" NAME="secondary_date_of_birth" VALUE="" SIZE="10" MAXLENGTH="10"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Social Security Number</font></td> <td ALIGN="left" COLSPAN="4"> <input TYPE="text" NAME="secondary_social_security_number" VALUE="" SIZE="9" MAXLENGTH="9"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Address</font></td> <td ALIGN="left" COLSPAN="4"> <input TYPE="text" NAME="secondary_current_street_address" VALUE="" SIZE="25" MAXLENGTH="100"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">City, State Zip</font></td> <td ALIGN="left" COLSPAN="4"> <input TYPE="text" NAME="secondary_current_city" VALUE="" SIZE="10" MAXLENGTH="30"> , <input TYPE="text" NAME="secondary_current_state" VALUE="" SIZE="3" MAXLENGTH="2"> <input TYPE="text" NAME="secondary_current_zip_code" VALUE="" SIZE="5" MAXLENGTH="5"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Home Phone Number</font></td> <td ALIGN="left" COLSPAN="4">( <input TYPE="text" NAME="secondary_current_home_area_code" VALUE="" SIZE="3" MAXLENGTH="3"> ) <input TYPE="text" NAME="secondary_current_home_phone_prefix" VALUE="" SIZE="3" MAXLENGTH="3"> - <input TYPE="text" NAME="secondary_current_home_phone_suffix" VALUE="" SIZE="4" MAXLENGTH="4"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Work Phone Number</font></td> <td ALIGN="left" COLSPAN="4">( <input TYPE="text" NAME="secondary_current_work_area_code" VALUE="" SIZE="3" MAXLENGTH="3"> ) <input TYPE="text" NAME="secondary_current_work_phone_prefix" VALUE="" SIZE="3" MAXLENGTH="3"> - <input TYPE="text" NAME="secondary_current_work_phone_suffix" VALUE="" SIZE="4" MAXLENGTH="4"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">Driver's License Number</font></td> <td ALIGN="left"> <input TYPE="text" NAME="secondary_driver_license_number" VALUE="" SIZE="12" MAXLENGTH="20"></td> <td ALIGN="right"><font size="-1" face="arial, helvetica">State</font></td> <td ALIGN="left"> <input TYPE="text" NAME="secondary_driver_state" VALUE="" SIZE="3" MAXLENGTH="2"></td> </tr> <tr> <td ALIGN="right"><font size="-1" face="arial, helvetica">E-mail</font></td> <td ALIGN="left" COLSPAN="4"> <input TYPE="text" NAME="secondary_e-mail_address" VALUE="" SIZE="25" MAXLENGTH="40"></td> </tr>  </table> <hr>  <table> <tr> <td COLSPAN="2"><FONT FACE="Arial,Helvetica" SIZE=-1> I (We) agree that the use of any Debit Card ("Card") issued in response to this application will constitute my (our) agreement to be secondaryly and severally bound by the terms and conditions of the Debit Card Agreement delivered with the Card. It is certified that the above information is complete and true, and is given to induce you to issue said Card(s). I (We) authorize you to make whatever credit and/or investigative inquires deemed necessary in connection with this application and to exchange with others regarding my (our) Card transactions. I (We) understand that this Card is not a Credit Card, and that no commitment to extend credit to me (us) will be made by your issuance of the Check Card(s) requested.</font> </td> </tr> </table> <table> <tr> <td COLSPAN="2"> <FONT FACE="Arial,Helvetica" SIZE=-1><input TYPE="checkbox" VALUE="Yes" NAME="terms_and_conditions_agreement"> I (We) aknowledge and agree to the terms and conditions as outlined above.</font> </td> </tr> </table>   <div align="center"> <p> <p> <input type="submit" value="Submit"> <input type="reset" value="Cancel"> <input type="hidden" name="currentState" value="submit"> <input type="hidden" name="form" value="check_card_app"> </div> </div> </form>   </body> </html>