PIN REQUEST FORM 

Date:_____________

I, ____________________________, request that my current personal identification number (PIN) be changed to the number I have selected and indicated below.

I will place my VISA debit card and this portion of the form in an envelope addressed to Electronic Banking.

I will place my PIN selection in an envelope addressed to Customer Service.

I have not shown anyone my new PIN selection.

Place this portion of the form in an envelope addressed to Electronic Banking.

VISA debit card #___________________

Signature of VISA debit card holder

___________________________________

Day Phone Number:___________________

Home Phone Number:__________________

- - - - - - - Separate form here- - - - - - - - - -

Personal Identification Number (PIN) Selection
Do not show your PIN selection to anyone. Place this portion of the form in an envelope addressed to Customer Service.
Print name as shown on card:

____________________________________

New PIN:_____ _____ _____ _____

This portion of the form will be destroyed immediately after processing.