APPLICATION FOR ATM CARD
  

DEPOSITOR
 Account Number
  
 Name (First - Middle - Last)
   
 Address
   
 City                                  State                                 Zip Code
   
 How Long At This Address
   		  Home Telephone
   
 Own home                                Rent                         Live w/parents
      [  ]                                       [  ]                                   [  ]
 Monthly Rent/Mortgage
   
 Previous Address (If Less than Three Years At Present Address)
   
 Date of Birth
   		  Social Security Number
   
 Mother's Maiden Name
   

DEPOSITOR'S EMPLOYER
 Employer
   		  How Long:
 Address
  
 City                                  State                                 Zip Code
   
 Position-Job Title
  		  Annual Income
  		  Telephone Number
  

 NOTICE: You need not list income from alimony, child support
 or separate maintenance if you do not want it considered

  

JOINT DEPOSITOR
 Name (First - Middle - Last)
  		  Issue another card in this
 name:   [  ] Yes   [  ] No
 Address (if different from depositor)
   
 City                                  State                                 Zip Code
   
 Date of Birth
  		  Social Security Number
  

JOINT DEPOSITOR'S EMPLOYER
 Employer
  		  How Long?
  
 Address
  
 City                                  State                                 Zip Code
   
 Position-Job Title
  		  Annual Income
  		  Telephone Number
  

Signatures: By signing below, the undersigned request(s) the described services and agrees to the terms and conditions governing the services, including any fees and charges. The undersigned agree(s) that all information is accurate and authorizes the financial institution to verify credit and employment history by any necessary means, including preparation of a credit report by a credit reporting agency.

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Signature of Depositor                                              Date

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Signature of Joint Depositor                                     Date
Mail or deliver application to:

INEZ DEPOSIT BANK
P.O. BOX 365
INEZ, KENTUCKY 41224
CURRENT DEBTS (Please attach another sheet if additional space is needed)
(check one or both) Creditor Mailing Address Present Balance Monthly Payments
      Depositor

 (1)		   Joint Depositor
  		            

 (2)		               

 (3)