Reloadable Debit Card Order Form

Reloadable Visa(R) Debit Card Order Form

Account Number *

Last Name *

First Name *

Middle Name or MI

Social Security Number *

Mother's Maiden Name *

Your Date of Birth *

Address *

City *

State *

Zip Code *

Phone *

Phone Type *

Mobile

Home

Work

Email *

Reloadable Visa® Debit Card Set-up

Minimum Initial Deposit *

I understand that if my initial load amount on my Reloadable Visa® Debit Card is less than $50.00, I will be assessed a one-time $5.95 cardholder fee..

Transfer

Transfer the following amount from my Credit Union Savings Account to my new Reloadable Visa® Debit Card.

Transfer Amount $

Other Deposit

I will be depositing additional funds into my Savings Account for the purpose of loading my new Reloadable Visa® Debit Card.

Agreement

I understand that my initial funds will not be loaded until I receive my new Reloadable Debit Card and notify the Credit Union to add the funds to card.

Electronic Funds Transfer Disclosure

Funds Availability Disclosure

Thank You for submitting your order for a new Reloadable Visa® Debit Card. We'll be processing it and let you know the progress.

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800.370.2260

memberservice@upcu.org