Georgia Heritage FCU

ATM Card/VISA® Check Card Application

PO Box 1920 Savannah, GA 31402 912-238-5944 (fax)

Type of card applying for:

ATM Card

Visa Check Card

Applicant

(Please Print)

MEMBER ACCOUNT: _________________

SHARE SAVINGS

SHARE DRAFT

# OF CARDS: _________

APPLICANT'S FULL NAME: ____________________________________________________________

MOTHER'S MAIDEN NAME: ____________________________________________________________

ADDRESS: ____________________________________________________________

CITY: _________________________ STATE: _________ ZIP: _________

SOCIAL SECURITY #: _________________________ DATE OF BIRTH: _____________________

TELEPHONE # (HOME): _________________ (WORK #): _________________

Co-Applicant

(If Applicable)

CO-APPLICANT'S FULL NAME: _______________________________________________________________

SOCIAL SECURITY #: _________________ DATE OF BIRTH: _________________

Signatures

(Both signatures are required for a Joint Account)

I/We agree to be bound by the terms and conditions of the Membership and Account Agreement, or the ATM/VISA Check Card(s) Services Agreement with Regulation E Disclosure, which will be sent with the ATM/VISA Check Card(s). The signature(s) below authorize(s) Georgia Heritage FCU to check credit, verify employment history and make other inquiries about this application.

_______________________________ (Applicant)	_______________________________ (Co-Applicant)
_______________________________ (Date)	You Must Print and Return to Credit Union (in person, by mail or by fax)