Debit Card Request Form

Please Check One:*

Replacement Card* New Card

REASON FOR REPLACEMENT CARD

Please Check One:*

Mail to address on file Mail to credit union Instant Issue (in branch request ONLY)

I hereby apply for a Shell Western States Federal Credit Union VISA ® Debit Card. By using my Shell Western States FCU Debit Card I agree to be bound by the applicable terms and conditions and any other agreements between the credit union and myself regarding my Share Account, Checking Account and any overdraft- protection agreement that I have with the credit union.

I will notify Shell Western States FCU immediately if the card or the PIN number is lost, stolen, or used by someone other than myself without my authorization. Debit Cards are the property of Shell Western States FCU, which may, without liability or advance notice, close or limit any or all cards in this agreement. Upon demand, I will surrender the card(s) to the credit union.

*Replacement Card and Pin fees apply. Please review our Fee Schedule on our website www.swsfcu.org or call (925)228-4545 option 2.

Member Number:*

Email Address:*

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:

Member Services

Advised member of our Card Nav (please initial if applicable):

Make sure member is aware that any automatics will be denied once card is closed.

Make sure member is aware card will not work once we close the card.

Charged for replacement (Please initial if applicable):

Charged for Rush Order (Please initial if applicable):

Processed by (CU*Base Employee ID):

Employee Signature:

[clear]

Use your mouse or finger to draw your signature above

Date:

Comments:

Manager Review

Audited by (CU*Base Employee ID):

Auditor Signature:

[clear]

Use your mouse or finger to draw your signature above

Date:

Auditor Comments: