Visa Debit Card Cancellation
Date (dd/mm/yyyy)
/
/
Member Number
Account Expiration Date (mm/yyyy)
Visa Card Number Cardholder Name
Address
City
State
S
/
Postcode
Email/s Home Phone/s
Was PIN with Card?
Mobile Phone/s
Yes
No
(If yes, refer to Terms and Conditions for member liability)
Date of Last Valid Transaction
Amount $
Note: I will advise any merchants to cancel any direct debits that are attached to this card. I will inform them of the new card number when it is received. I advise that I no longer require my Visa Card and request that you cancel it. I understand that my account will remain active for 45 days to allow for any outstanding transactions to be processed and that I am required to adjust any overdrawn balances due to these transactions.
Signature
Note: If a replacement card is not required (eg. a/c closure) and there are no other Visa cards attached to this account the Visa facility is to be cancelled. HOTLINE: 1 800 648 027 Ref # FRONT OFFICE USE ONLY Received by: Op. No.
Date:
Address details checked: (P & R)
If the address has been amended, please complete section below: Security questions asked and updated Address amended: (P & R - edit `Address Details') Other services notified (MyCard, QBE): Linked member address updated?
Yes
No
Yes
No
Yes
No
Yes
No
Member Signature Verified: First A/c type to be accessed:
BACK OFFICE USE ONLY
S
(P & R - P811 - Maintain Accounts) Letter # 355 mailed
Photocopy of both sides of card Original card destroyed if sighted Diary note loaded to close account in 45 day FRM 0137 9/0815
A Visa Card access changed:
Op. No.
Date:
288 Summer Street, PO Box 992, Orange NSW 2800 Tel: 02 6362 4466 • Fax: 02 6363 1208 • Rediphone: 02 6361 1166 DX: 3041 • BSB: 802 129 • ABN 34 087 650 477 • AFSL 240768 Email:
[email protected] • www.orangecu.com.au
Page 1 of 1
