Debit Card Application

Apply for a Highlands Bank ATM or Visa Debit Card!

In order to apply for a card for your account, please complete the form below. If your card has been lost or stolen, or if you have any questions about completing the application, please call our service center at (304) 257-4111. Please note - if the account requested is a joint account, both owners should complete this form.

General

• Please choose a card type

  • ATM Card
  • Visa Check/Debit Card
  OK Please choose a card type is required

Applicant

• Account Number
  OK Account Number is required
• Business Name (if applicable)
  Optional OK Business Name (if applicable) is required
• First Name
  OK First Name is required
• Middle Initial
  Optional OK Middle Initial is required
• Last Name
  OK Last Name is required
• Suffix IIIIIIIVJr.Sr.
  Optional OK Suffix is required
• Address
  OK Address is required
• City
  OK City is required
• State AK - AlaskaAL - AlabamaAR - ArkansasAZ - ArizonaCA - CaliforniaCO - ColoradoCT - ConnecticutDC - District of ColumbiaDE - DelawareFL - FloridaGA - GeorgiaHI - HawaiiIA - IowaID - IdahoIL - IllinoisIN - IndianaKS - KansasKY - KentuckyLA - LouisianaMA - MassachusettsMD - MarylandME - MaineMI - MichiganMN - MinnesotaMO - MissouriMS - MississippiMT - MontanaNC - North CarolinaND - North DakotaNE - NebraskaNH - New HampshireNJ - New JerseyNM - New MexicoNV - NevadaNY - New YorkOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVA - VirginiaVT - VermontWA - WashingtonWI - WisconsinWV - West VirginiaWY - Wyoming
  OK State is required
• Zip Code
  OK Zip Code is required

• Daytime Phone Number

  - -
  OK Daytime Phone Number is required

• Home Phone Number

  - -
  Optional OK Home Phone Number is required

• Social Security Number

  - -
  OK Social Security Number is required

• Birth Date

  JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 2026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900
  OK Birth Date is required
• E-mail Address
  OK E-mail Address is required
• Employer
  OK Employer is required

• How would you prefer to be contacted?

  • Please do NOT email me important news and updates.
  • Home Phone
  • Work Phone
  • Email
  • Other
  OK How would you prefer to be contacted? is required
• Other
  OK Other is required

Authorization

By clicking on the "I Accept" button below, I am applying for a Highlands Bank Visa Debit Card or ATM Card. I understand this is not a credit card and that the dollar amount of the purchases made with this card will be deducted from my Grant County Bank checking account listed above. I authorize Grant County Bank to verify the information provided above and to request a credit report or other consumer data information if necessary. The Grant County Bank Visa Debit Card is available for qualified customers only. Other requirements apply. I agree to be bound by the terms and conditions covered in the appropriate Discloser Statement and Cardholder Agreement. Check the "I Accept" button to indicate that you (the applicant) have read the agreement and accept its terms.

• • I Accept
  OK I Accept is required