Debit Card Request Form

Quantity Requested

Order a Debit Card Only for the Primary Member

Order a Debit Card Only for the Joint Owner

Order a Debit Card for Both the Primary Member and Joint Owner

Re-Order my Debit Card with the same number (for damaged cards only)

Re-Order my Debit Card with a new number (for lost, stolen or fraudulent activity)

Reason for Re-Order

Account Information

Account Number *

Primary Member Name *

Joint Owner Name (If Applicable)

Street Address *

City/State/Zip Code *

Enter Primary Owner Phone Number *

Enter Joint Phone Number (If Applicable)

Primary Owner Email *

Joint Owner Email (If Applicable)

Authorization Agreement

I understand that I must already have a checking account in good standing with PSCU to request a debit card. The primary owner must sign an agreement whether they are requesting a debit card for themselves or not. The Joint Owner must sign if they are requesting a debit card. Requests are subject to approval. If it has been approved, a form will be sent out for appropriate parties involved to sign before any cards will be ordered.

How would you like to receive your card(s):

Mailed (arrives in 7 to 10 business days)

Pick up at Jefferson (When Ready)

Cards can be printed and available for pick up during regular business hours at our Jefferson Office. These instant issue cards can only be used with the chip or by entering the card number manually, the magnet strip will never work.

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