ATM Card/VISA® Check Card Order Request

* indicates a required field

Primary Owner’s Name
 Account #:
 Phone No:
*Address:
 *City                         *State:
  		*Zip:
Name on Card Being Replaced (if different from the primary owner):
Joint Owner’s Address (if applicable):
 City                         State:
,  		Zip:
Previous Address (Required if requesting a new card within 30 days of an address change):
Address:
 City                         State:
,  		Zip:
ATM Card/VISA ® Check Card Order
I am aware that there will be a $10.00 fee to obtain a new card. I understand that I am responsible for reporting lost/stolen check cards or unauthorized transactions immediately, in accordance with the terms and conditions of my account, and may be responsible for unauthorized transactions to the extent permitted by law. I understand that this new card will be issued with a computer generated PIN. This PIN can be changed later by calling Allegacy's Member Services. For assistance with this form, I will contact Member Services at 336.774.3400/800.782.4670.
No existing card. New order.
I no longer want a card. Please cancel it.
Card is in my possession but does not work.
Magnetic strip not reading
Card bent or damaged
Name Change (Documentation has been provided to the credit union)
For lost or stolen cards please contact Member Services at 336.774.3400/800.782.4670 immediately.
Last 4 digits of Card Number:
* indicates a required field