VISA Debit Card Request

To request a VISA Debit Card, please fill out this application and submit it to Bluestem (This is a secure form).
Alternatively, the page can be printed and mailed to Bluestem Bank, 104 East Locust, Fairbury, IL 61739.

Name:
Address:
City, State Zip: , ,
Phone: Home: Business:
User ID
Birth Date mm/dd/yyyy:
Mother's Maiden Name:
E-mail Address:

Your options for submission are listed below. If you "Securely Submit" this, our Customer Service Department will mail the final application for your signature upon approval of your Visa Card request. If you "Print and Mail" this form and sign the form prior to mailing it to the address displayed above, our Customer Service Department will promptly process your request upon approval of the application.

With either option, you can expect to receive your new Visa Debit card in the mail within two weeks from the time we order the card. For new card requests (versus card replacement requests), the PIN number will be mailed under separate cover a couple days after the card is mailed to you. For card replacements, your PIN number will not change.

Please read the following information before continuing with your application:


I have viewed the above Information on Electronic Fund Transfers - Your Rights and Responsibilities.