Change of Address Form

Member Number(s):*

Primary Member's Name:*

First Name

Initial (optional)

Last Name

Suffix (optional)

Joint Owner's Name:

First Name

Initial (optional)

Last Name

Suffix (optional)

Home Phone:

Cell Phone:

Work Phone:

Email Address:

Residential Address (P.O. Box not allowed)

Previous Residential Address:

Address Line 1

Address Line 2

City

State

ZIP Code

New Residential Address:

Address Line 1

Address Line 2

City

State

ZIP Code

Mailing Address (Optional)

Previous Mailing Address:

Address Line 1

Address Line 2

City

State

ZIP Code

New Mailing Address:

Address Line 1

Address Line 2

City

State

ZIP Code

Authorization and Signatures

I authorize Shell Western States Federal Credit Union to change my address in the manner above and certify that all the information provided by me is correct.

Primary Member's Signature:*

[clear]

Use your mouse or finger to draw your signature above

Date:*

Joint Owner's Signature:

[clear]

Use your mouse or finger to draw your signature above

Date:

*Primary member or Joint owner’s signature is required before change of address request can be processed.*

Member Services

Verified Member with 3 out of Wallet Questions (please initial)

Received in branch, Mail, Night Drop (Please specify & initial)

Received in via email (completed form was attached) (Please initial):

Received in via online digital form (Please initial):

Verified and updated all phone numbers and email (Please initial):

If member has debit card, Verify all information in COOP (Initial or N/A if no Card)

Processed by (CU*Base Employee ID):

Update address in CPS (initial or N/A if no checks)

Employee Signature:

[clear]

Date:

Comments:

Manager Review

Audited by (CU*Base Employee ID):

Auditor Signature:

[clear]

Date:

Auditor Comments: