ATM/Debit Maintenance

* Required Fields

Cardholder Name:

Street Address:

City:

State:

Zip:

Primary Phone:

Phone::

Primary Cell

Primary Home

Primary Work

Alternate Phone Number:

Alternate Phone:

Alternate Cell

Alternate Home

Alternate Work

Email Address:

Account #:

Visa CheckCard #432882:

ATM Card #640845:

I Request to:

Change My Name and Issue a New Card

Close My ATM Card and Issue Me a Debit Card

Close My ATM Card

Close My Debit Card

Permit Deposit Access

Replace My Damaged Card

Electronic Signature (e-Signature): You consent and agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action while using any electronic service we offer; or in accessing or making any transactions regarding any agreement, acknowledgement, consent, terms, disclosures or conditions constitutes your signature, acceptance and agreement as if actually signed by you in writing. Further, you agree that no certification authority or other third party verification is necessary to validate your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or resulting contract between you and ASECU.

You understand and agree that your e-Signature executed in conjunction with the electronic submission of your application and/or form shall be legally binding and such transaction shall be considered authorized by you.

By signing below, I acknowledge that the information provided is correct. I further understand that Associated School Employees Credit Union stores applications and forms electronically and the original document may not be retained. I agree that the electronically stored document and signature will serve as the original document(s) for all intents and legal purposes.

I Agree:

I have read and agree to the statements listed above.

Cardholder Signature:

Date:

/ /

Security Code: