Golden Plains Credit Union - Card Travel Exclusion Form

In an effort to have your debit and/or credit card work properly while you are traveling, please fill out the form below to notify us of when and where you will be traveling so that we can note this on your account. This form is for traveling up to 3 weeks only. If you plan to travel more than 3 weeks, please contact your local branch directly so that we can explain the Card Hold Harmless form that we will need you to sign for your travels.

Card & Travel Information
Account Number	Credit Card Number	Debit Card Number

Travel Dates	Travel Locations
(ex: mm/dd/yyyy thru mm/dd/yyyy)	(please list all of the states you will be traveling through where you will use your card)

Security Information

Phone Number

Email Address

Account Password

() -

Signature

Date (mm/dd/yyyy)

(please give us the best contact number to reach you at any time)

Please enter the security code below prior to submitting the form.