Debit Card Application - Go Energy Credit Union

I am applying for: (Debit Card Type)

A new Visa Debit Card
A replacement Visa Debit Card for lost card
A replacement Visa Debit Card for damaged / stolen card

Fee may apply - refer to Fee Schedule

First Name

Middle Initial

Last Name

Address1

Address2

City

State

Zip

Email

Home Phone

Work Phone

Cell Phone

Member Account Number

Mother's Maiden Name

Joint Owner

Joint Account Owners Information (if applicable)

Name — Joint Owner

Email — Joint Owner

Home Phone — Joint Owner

Work Phone — Joint Owner

Mother's Maiden Name — Joint Owner

Agreement

I (We) agree to abide by the terms and conditions which have been disclosed to me. My (our) check in the box below authorizes you to receive information about me (us) or about my (our) credit accounts with other people. I (We) acknowledge the receipt of the Electronic Funds Transfer Disclosure & Agreement. By retaining, using or authorizing another person to use my (our) personal security code or card, I (we) shall be liable for all transactions and charges made in connection with the service.

Signature Agreement

By submitting this application electronically, I/we agree to the same terms that apply to a signed application. If there is a co-applicant on this loan, that co-applicant has authorized the submission of this application. This electronic submission qualifies as my/our signature.

Signature

Date

Joint Owner Signature (if applicable)

Date — Joint Owner

VISA Account Updater

VISA Updater OPT OUT

Whenever you receive a new, or renewed, VISA card, your old card's information (i.e., card number and expiration date) will automatically update to the new card's number and expiration date - for participating merchants with whom you maintain your card on file for recurring payments. YOU MAY OPT OUT: By checking the box, I wish to opt out of VISA Account Updater (VAU) for my Go Energy Financial Debit Card. I understand it will be my responsibility to notify merchants, who maintain my card on file information for recurring payments with any updated information regarding my Go Energy Financial Debit Card.