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Reloadable Debit Card Receipt and Acknowledgement

  1. The individual shown as the customer on this form is receiving a debit card that will be loaded with funds to assist them in completing workforce-supported activities.
  2. Acknowledgement of Terms of Use of Potential Fees
    • Customer will be responsible for securing the card. • Customer assumes full responsibility if funds on the card are used by an unauthorized person or for unauthorized purposes—those funds will not be replaced. • Customer has received a copy of the Card Agreement and Terms of Use, including a schedule of Fees and understands that use of this card at an ATM or a bank may include fees that will be automatically deducted from the card balance. • Customer understands that the use of this card where entry of a PIN is required may result in a fee being automatically deducted from the card balance. • Customer agrees to immediately contact their Career Specialist (identified above) at Workforce Solutions in the event the card is lost or stolen. • Customer understands that the funds made available on the debit card are solely for the purpose of participation in workforce activities and agrees to use them only for that reason. • Customer understands that illegal or other misuse of the debit card/funds may result in consequences that include (but are not limited to) ineligibility for workforce services as well as legal action.
  3. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that: your application will not be signed in the sense of a traditional paper document, by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, you may still be required to provide a traditional signature at a later date.
  4. I hereby accept these terms.
  5. Equal Opportunity Employer/Program
    Auxiliary aids and services are available upon request to individuals with disabilities. Relay: 1-800-735-2989 (TTY) / 711 (Voice). Este documento contiene información importante sobre los requisitos, los derechos, las determinaciones y las responsabilidades del acceso a los servicios del sistema de la fuerza laboral. Hay disponibles servicios de idioma, incluida la interpretación y la traducción de documentos, sin ningún costo y a solicitud.
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