Secure Visa Debit Card Application
1626 17th Street, Lewiston, Idaho 83501
Phone: (208) 746-7233 • Fax: (208) 746-0426

All Fields Are Required
Your Member Acct. Number:
Your Email Address:
First Name:
Middle Name or Initial:
Last Name:
Street Address:
City:
State:
   Zip:
Home Phone #:
Cell Phone #:
Work Phone #: Ext:
Last 4 of Social Security #:
Birthdate (MM/DD/YY):

  By submitting this request, I acknowledge that I have read and agree to the terms of the Visa Debit Card Disclosure