Debit Card Verification and Limit Increase Agreement

To verify a debit card or apply for a limit increase, please complete the agreement below:

  1. For each debit card, enter the account information and print the form.
  2. In the space provided at the bottom of the agreement, make an imprint of your debit card by placing the card under the printed form and very lightly rubbing a pencil over the top.
  3. Sign and date the bottom of the agreement.
  4. Scan and email the Debit Card Verification Agreement(s) along with:
a photocopy of picture ID
(e.g. Drivers License)
Photocopies (front and back) of your debit card

To avoid processing delays, please ensure that the name, address, account number and signature on your submitted documents are clearly legible.

Client Information

General Information
Debit Card Information

IMPORTANT: Please read the following carefully before signing and dating.

By submitting this signed and dated form, along with the additional information requested, I am authorizing and fully acknowledging that:

  1. I am the person who opened this account personally, entered into all transactions, and deposited eCash using the above debit card.
  2. I will honor all eCash deposits made in my account and pay for them in full, whether purchases made by telephone or by Internet.
  3. I agree that any and all uncollected purchases or delinquent accounts are subject to 3rd party credit reporting and collections.
  4. I am over 18 years of age
  5. I have read and accepted the terms described in the Transaction Processing Agreement.




Signature Date

Making an imprint of your Debit Card
  1. Place Debit Card under box outline.
  2. Rub pencil very lightly over card.
  3. Ensure that the name, number, and expiration date are clear and readable.

 

Fax To

    +800-1004-2005