Debit Card Request/Reorder

* Indicates Required

• CARDHOLDER INFORMATION

  Cardholder Name*

  Member Number*

  Email*

  Mother's Maiden Name*

  Date of Birth*

  Street Address*

  City*

  State*

  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Zip Code*

  Please Mail Card to different address

  Mailing Address*

  City*

  State*

  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Zip Code*

  Cell Number *

  Work Phone Number *

  Other Phone Number *

  At least one phone number is required.

  Rush Card Order ($40.00 Fee Applies).

  Charge to account*

  Checking Savings

  Account to charge is required.

  
  

• CARD INFORMATION

  Reason for Request/Re-Order:*

  First-Time Order Re-Order: Stolen/Fraud Re-Order: Damaged/Lost

  Reason is required

  First replacement (free) / Additional Replacement see fee schedule

  
  

• ACKNOWLEDGEMENT

  By signing below, I am requesting an Actors Federal Credit Union Debit Card and agree to utilize the card in accordance and adherence to ActorsFCU Membership Agreement which is amended from time to time. I hereby certify that all information on this request form is true and complete to the best of my knowledge. I expressly authorize any person, association, firm, corporation, personnel office requested by ActorsFCU to furnish information concerning me or my financial affairs, including preparation of a credit report by a credit reporting agency. This request form will remain the property of ActorsFCU whether or not a Debit Card is granted. I understand and agree to the “Replacement Card” fee listed on ActorsFCU's fee schedule. I accept the terms of the agreement and other terms as may be determined by ActorsFCU from time to time.

  A debit card transaction is considered “authorized” by the cardholder if the card or card number is willingly provided either to a merchant or to another person. Issues with authorized transactions must be reported to the credit union as soon as you become aware of the transaction but no later than 60 days of the date you receive your periodic statement on which the transaction appears. Authorized transactions will be handled as merchant disputes.

  A debit card transaction is considered “unauthorized” if the debit card or card number is used by a merchant or person other than the cardholder, who did not have actual, implied or apparent authority for said use. Unauthorized transactions must be reported to the credit union as soon as you become aware of the transaction but no later than 60 days of the date you receive your periodic statement on which the transaction appears.

  
  

• Signature

  Cardholder Signature*

  Clear Signature

  Date*

  
  

  To verify your identity, please attach a valid ID below

  Accepted ID types include: government issued photo ID, i.e.: State issued driver's license, US passport, or equivalent.

  An Attachment is required.

  Select files from your computer
  or simply drag & drop them here

  Accepted formats: .pages, .doc, .docx, .pdf, .png, .jpg.