*1.Agency(Required.)

2.Name

*3.Email(Required.)

4.Card Number(s)

If you have a blue card, this number is an eight-digit number on the bottom left of the front of the card. If you have a black card, this number will be on the back of the card and is 19 digits long. Please do not include spaces.

If you have more than 10 cards you wish to deactivate, please complete this form as many times as is needed.

Card 1

Card 2

Card 3

Card 4

Card 5

Card 6

Card 7

Card 8

Card 9

Card 10