Credit Card Application
Application Type: Individual Account Joint Account Individual Account with authorized user
Member Account Number:
If you are applying for credit in your name only, please omit the portion for co-applicant.
Applicant:
Name
First Name
MI
Last Name
Home Address
Street
City
State
Zip
How Long?

Months
Previous Home Address
Street
City
State
Zip
How Long?

Months
Home Phone

000-000-0000 		Birth Date
 /  / 
mm
dd
yyyy
Ages of Dependents
Social Security No.

000-00-0000		 Mother's Maiden Name
Driver's License Number & State
  
Business Phone

000-000-0000 		Gross Annual Income
Net Monthly Pay
Employer

 Position

 How Long?

Months
Business Address

Street, City, State, Zip
Previous Employer Position
 How Long?

Months
Previous Business Address

Street, City, State, Zip
Alimony, Child Support, or separate maintenance income do not need to revealed if you do not wish to have it considered as a basis for repaying this obligation.
Alimony, child support, separate maintenance received under:
Court Order Written Agreement
Oral Understanding
Other Income: per
Source(s) of other income:
Is any income listed in this Section likely to be reduced in the next two years?
Yes (Explain in box below) No
 
Co-Applicant:
Name
First Name
MI
Last Name
Home Address
Street
City
State
Zip
How Long?

Months
Previous Home Address
Street
City
State
Zip
How Long?

Months
Home Phone

000-000-0000 		Birth Date
 /  / 
mm
dd
yyyy
Ages of Dependents
Social Security No.

000-00-0000		 Mother's Maiden Name
Driver's License Number & State
 
Business Phone

000-000-0000		 Gross Annual Income
 Net Monthly Pay
Employer
 Position
 How Long?

Months
Business Address

Street, City, State, Zip
Previous Employer Position
 How Long?

Months
Previous Business Address

Street, City, State, Zip
Alimony, Child Support, or separate maintenance income do not need to be revealed if you do not wish to have it considered as a basis for repaying this obligation.
Alimony, child support, separate maintenance received under:
Court Order Written Agreement
Oral Understanding
Other Income: per
Source(s) of other income:
Is any income listed in this Section likely to be reduced in the next two years?
Yes (Explain in box below) No

Outstanding Debts Include charge account, installment contract, credit card, rent, mortgages, etc.
Use explaination box below if necessary
Mortgage or Landlord Payment Address
Approx. Market Value Original Amount
 Balance Due
 Monthly Pmt/ Rent Amount
Autos Owned - Make Year License No. Financed By
Other Debts - Name and Address Account Number
Additional Information
Checking/ShareDraft Acct Number
 Location
Savings Account Number Location
Total of Payments
Reference: Nearest relative not living with you
Name
Relationship
City
State
Zip
Are you a co-maker, endorser, or guarantor on any loan or contract?
Yes No 		If "yes", for whom?
To whom? (Creditor)
Are there any unsatisfied judgments against you?
Yes No 		Amount If "yes", To whom owed?
Other Obligations (e.g., liability to pay alimony, child support, separate maintenance.
Use explaination box below if necessary.)
Have you ever had a car or other personal property repossessed by a dealer or finance company, filed for bankruptcy, or been a party to a wage assignment or collection suit, or have you ever been declined on a loan application to this credit union? Yes No

If your answer is yes to part of this question is yes, please give details.

PLEASE ANSWER THE FOLLOWING ONLY IF YOU RESIDE IN A COMMUNITY PROPERTY STATE (ARIZONA, CALIFORNIA, IDAHO, LOUISIANA, NEVADA, NEW MEXICO, TEXAS, WASHINGTON OR WISCONSIN) OR IF ANOTHER PERSON WILL BE JOINTLY LIABLE ON THE ACCOUNT.

Marital Status:      Married              Separated              Unmarried
Explanation:

This statement is submitted to obtain credit and I/we certify that all information herein is true and complete. I/We also authorize the credit union to verify or obtain further information the credit union may deem necessary concerning my/our credit standing. If this application is approved and credit card(s) issued, the undersigned applicant(s) by signing, using or permitting another to use the credit card(s) agree(s) that the applicant(s) will be bound by the terms and conditions accompanying the credit card(s) and all amendments.


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