PO Box 576
Credit Card Authorized User Request
Seattle, WA 98111-0576
888.628.4010
inspirusCU.org
Date:_________________ Credit Card Number, if available:________________________________________
Member Name/Business Name: _______________________________________________________________
Member Number: __________________________________________________________________________
Home#: _______________________ Work#: _______________________ Cell#: ________________________
AUTHORIZED USER 1
(Minimum age 14)
Name:_________________________________________________________________________________
Date of Birth:_____________________ Social Security Number:_________________________________
MMN:___________________________ Address:______________________________________________
Would you like to have a card issued to this user with the name as it is typed above? Yes No
We may report information about your account to credit bureaus. Late payments, missed payments, or other defaults on your account may be reected in your credit report.
Signature: ______________________________________________ Date: _____________
AUTHORIZED USER 2
(Minimum age 14)
Name:_________________________________________________________________________________
Date of Birth:_____________________ Social Security Number:_________________________________
MMN:___________________________ Address:______________________________________________
Would you like to have a card issued to this user with the name as it is typed above? Yes No
We may report information about your account to credit bureaus. Late payments, missed payments, or other defaults on your account may be reected in your credit report.
Signature: ______________________________________________ Date: _____________
REMOVE AUTHORIZED USER
(Cannot remove joint)
Name: ________________________________________________________________________________
NO
Does Account Need New Card Number?
YES
I hereby authorize the users above to be added as an Authorized User to the credit card account listed
above. I certify that I am the account owner, that I have full authority to make changes to this account and
that an unrestricted card will be issued to this person. I also understand that I am responsible for any
charges done by the authorized user, as well as on-time repayment of this account.
Signature of the Cardholder (Primary or Joint): __________________________________ Date: _________
Please mail this signed document to:
Inspirus Credit Union
P.O. Box 576 - Seattle, WA 98111-0576
20191031001 10/19
Or, fax to: 206-676-3649
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