ATM/Debit Card Application * Required Fields Name as it appears on Card: Organization Name: Street Address: City: State: Select... AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip: Primary Phone Number: Primary Phone: Primary Cell Primary Home Primary Work Alternate Phone Number: Alternate Phone: Alternate Cell Alternate Home Alternate Work Email Address: Account Number: Personal Identification Number (PIN)A Personal Identification Number (PIN) is a four digit numeric identification known only to you. This is an important safety feature. Your card cannot be used at an ATM without your PIN. Do not share your PIN with anyone. By giving someone your PIN you are authorizing their use of your card. You will assign a PIN when you activate your card. The Credit Union does not maintain a copy of your PIN. Acknowledgement and Authorization 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 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 also acknowledge that I have received the Cardholder Agreement and accept the terms and conditions herein. In addition, I grant Associated School Employees Credit Union permission to request a credit report to approve this application. 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. Signature: Date:: Date:: Month Month... January February March April May June July August September October November December / Date:: Day Day... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Date:: Year Year... 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 Confirm: I have read and agree to the terms listed below in the Agreement & Disclosure Statement. ATM/Debit Card Agreement and Disclosure Statement Security Code: Security Code Go to main navigation
