Money Si

First Name:		Middle Initial:		Last Name:

Date of Birth (MM/DD/YYYY):						Social Security Number:		Mother's Maiden Name (optional):

Home Street Address:		Apt #:

City:		State:		Zip code:

Home Phone:		Cell Phone:		E-mail Address:

Please select one:
	Standard	Flexible

Monthly service	$2.50	Free

Signature and PIN purchase	Free	$1.00

ATM balance inquiries	Free	$.50

ATM withdrawal (domestic)	$2.00	$2.00

ATM withdrawal (international)	$3.00	$3.00

I would like a companion card issued		Companion Card Holder's Name
Yes No

The USA PATRIOT Act is a Federal law that requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. You will be asked to provide your name, address, date of birth, and other information that will allow us to identify you. You may also be asked to provide documentation as proof of identification.

		Please enroll me. Upon receipt of my card, I will review the terms and conditions carefully before activating.