5702 W. US HWY 2, Hurley, WI 54534
Phone: (715) 561-2842  •  Fax: (715) 561-3364
Secure Check Card Application
Applicant Information
Account Number:
Name (First M. Last):
Social Security Number:
Date of Birth (mm/dd/yyyy):
Address:
City, State:
,
Zip-Plus4:
-
Home Phone Number:
( ) -
Work Phone Number:
( ) -
Employer:
Date Hired: Month: Year:
 
Co-Applicant Information (If Applicable)
Name (First,M.,Last):
Social Security Number:
Date of Birth (mm/dd/yyyy):
Home Phone Number:
( ) -
Employer:
Date Hired: Month: Year:
Work Phone & Ext:
( ) - -

This statement is submitted to obtain a check card and I certify that all information is true and complete. I authorize the credit union to verify or obtain further information it may deem necessary concerning my credit standing. If this application is approved and a check a card issued, by signing, using or permitting another to use the check card, I agree that I will be bound by the terms and conditions accompanying the Visa check card and all amendments. I understand that a Personal Identification Number (PIN) will be mailed to me in the event this application is approved. In the event ICCCU elects not to issue a check card.

I (We) acknowledge and agree to the terms and conditions as outlined above.

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