Please Check One:  ____ ATM Card  ____ VISA®Check Card

Your PIN is randomly selected and will be sent in a separate mailing.

Account Number__________________________________

Member Name____________________________________

Address (No P.O. BOX) ____________________________

City____________________State________ Zip_________

Date of Birth_____________________________________

Phone No.______________________________________

E-mail_________________________________________

Do you want a card in joint owner's name?  _____yes  _____no

Joint Member Name_____________________________

Address ______________________________________

City____________ State____ Zip________

To apply for an Atlantic FCU VISA®Check Card, you must have an Atlantic FCU Checking Account. If you would like 24-hour ATM Access and do not have an Atlantic FCU Checking Account, your application will be processed for an Atlantic Federal CU ATM Card.

Member Signature & Date__________________________________________________

Joint Member Signature & Date____________________________________________