VISA Card Application

* Indicates Required

• Step 1

  What type of card are you applying for?

  Application Type *

  Individual Individual with Authorized User Joint

  Application Type is required

  Credit Limit Requested *
• Step 2

  Tell us about you

  First Name *

  Last Name *

  Date of Birth *

  Primary Phone *

  Work Phone *

  Email *

  How would you prefer we contact you? *

  Primary Phone Work Phone Email

  Preferred Contact Method is required
• Step 3

  Where do you live?

  Address *

  Address Line 2

  City *

  State *

  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Zip *

  Do you own your house? *

  Rent Own Live With Parents

  Housing Type is required

  Do you owe mortgage? *

  Yes No

  Whether you owe mortgage is required

  Mortgage Holder

  Mortgage Balance

  Mortgage Payment

  Mortgage Holder or Landlord Name

  Monthly rent or board

  Have you lived at your current residence for more than 2 years? *

  Yes No

  Whether you have lived at your current residence for more than 2 years is required

  Tell us about your previous address

  Previous Address

  Previous Address Line 2

  Previous City

  Previous State

  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Previous Zip
• Step 4

  Identifying Information

  We need this information to verify your identity. Information passed through this form is secure.

  Account Number

  Social Security Number *

  Driver's License Number

  Drivers License State

  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Step 5

  Employment Information

  Are you self employed? *

  Yes No

  Employment Status is required

  Yearly Income

  Have you been self employed for more than two years? *

  Yes No

  How long you have been self-employed is required

  Tell us about your previous job

  Job Title*

  Employer Name*

  Employer Address*

  City*

  State*

  Alabama Alaska Arizona Arkansas Cadivfornia Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carodivna North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carodivna South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Zip*

  Employed From*

  To*

  Gross salary per pay period

  Pay frequency*

  Monthly Bi-weekly Weekly Semi-monthly

  Have you worked at another job within the past 2 years?*

  Yes No

  Whether you have another previous employment is required

  Previous Job

  Job Title*

  Employer Name*

  Employer Address*

  City*

  State*

  Alabama Alaska Arizona Arkansas Cadivfornia Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carodivna North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carodivna South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Zip*

  Employed From*

  To*

  Gross salary per pay period

  Pay frequency*

  Monthly Bi-weekly Weekly Semi-monthly

  Have you worked at another job within the past 2 years?*

  Yes No

  Whether you have another previous employment is required

  Previous Job

  Job Title*

  Employer Name*

  Employer Address*

  City*

  State*

  Alabama Alaska Arizona Arkansas Cadivfornia Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carodivna North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carodivna South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Zip*

  Employed From*

  To*

  Gross salary per pay period

  Pay frequency*

  Monthly Bi-weekly Weekly Semi-monthly

  Have you worked at another job within the past 2 years?*

  Yes No

  Whether you have another previous employment is required

  Previous Job

  Job Title*

  Employer Name*

  Employer Address*

  City*

  State*

  Alabama Alaska Arizona Arkansas Cadivfornia Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carodivna North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carodivna South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Zip*

  Employed From*

  To*

  Gross salary per pay period

  Pay frequency*

  Monthly Bi-weekly Weekly Semi-monthly
• Step 6
  Do you have an additional source of income? *

  Yes No

  Whether you have additional income is required

  Additional income source *

  Overtime Part Time Rental Income Alimony Child Support Maintenance Other

  Additional income source is required

  Additional Income: Other Source

  Additional Income Gross Monthly Amount

  Is your income likely to decline in the next two years? *

  Yes No

  Whether your income is likely to decline is required
• Step 7

  Joint Applicant Information

  Authorized User Information

  We also need information about your Joint Applicant the Authorized User! The next few pages (with "Joint ApplicantAuthorized User Information" at the top) ask questions about your Joint Applicantthe Authorized User.

  Tell us about you

  First Name *

  Last Name *

  Date of Birth *

  Primary Phone *

  Work Phone *

  Email *

  How would you prefer we contact you? *

  Primary Phone Work Phone Email

  Preferred Contact Method is required
• Step 8

  Joint Applicant Information

  Authorized User Information

  Where do you live?

  Address *

  Address Line 2

  City *

  State *

  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Zip *

  Do you own your house? *

  Rent Own Live With Parents

  Housing Type is required

  Do you owe mortgage? *

  Yes No

  Whether you owe mortgage is required

  Mortgage Holder

  Mortgage Balance

  Mortgage Payment

  Mortgage Holder or Landlord Name

  Monthly rent or board

  Have you lived at your current residence for more than 2 years? *

  Yes No

  Whether you have lived at your current residence for more than 2 years is required

  Tell us about your previous address

  Previous Address

  Previous Address Line 2

  Previous City

  Previous State

  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Previous Zip
• Step 9

  Joint Applicant Information

  Authorized User Information

  Identifying Information

  We need this information to verify your identity. Information passed through this form is secure.

  Account Number

  Social Security Number *

  Driver's License Number

  Drivers License State

  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Step 10

  Joint Applicant Information

  Authorized User Information

  Employment Information

  Are you self employed? *

  Yes No

  Employment Status is required

  Yearly Income

  Have you been self employed for more than two years? *

  Yes No

  How long you have been self-employed is required

  Tell us about your previous job

  Job Title*

  Employer Name*

  Employer Address*

  City*

  State*

  Alabama Alaska Arizona Arkansas Cadivfornia Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carodivna North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carodivna South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Zip*

  Employed From*

  To*

  Gross salary per pay period

  Pay frequency*

  Monthly Bi-weekly Weekly Semi-monthly

  Have you worked at another job within the past 2 years?*

  Yes No

  Whether you have another previous employment is required

  Previous Job

  Job Title*

  Employer Name*

  Employer Address*

  City*

  State*

  Alabama Alaska Arizona Arkansas Cadivfornia Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carodivna North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carodivna South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Zip*

  Employed From*

  To*

  Gross salary per pay period

  Pay frequency*

  Monthly Bi-weekly Weekly Semi-monthly

  Have you worked at another job within the past 2 years?*

  Yes No

  Whether you have another previous employment is required

  Previous Job

  Job Title*

  Employer Name*

  Employer Address*

  City*

  State*

  Alabama Alaska Arizona Arkansas Cadivfornia Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carodivna North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carodivna South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Zip*

  Employed From*

  To*

  Gross salary per pay period

  Pay frequency*

  Monthly Bi-weekly Weekly Semi-monthly

  Have you worked at another job within the past 2 years?*

  Yes No

  Whether you have another previous employment is required

  Previous Job

  Job Title*

  Employer Name*

  Employer Address*

  City*

  State*

  Alabama Alaska Arizona Arkansas Cadivfornia Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carodivna North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carodivna South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Zip*

  Employed From*

  To*

  Gross salary per pay period

  Pay frequency*

  Monthly Bi-weekly Weekly Semi-monthly
• Step 11

  Joint Applicant Information

  Authorized User Information

  Do you have an additional source of income? *

  Yes No

  Whether you have additional income is required

  Additional income source *

  Overtime Part Time Rental Income Alimony Child Support Maintenance Other

  Additional income source is required

  Additional Income: Other Source

  Additional Income Gross Monthly Amount

  Is your income likely to decline in the next two years? *

  Yes No

  Whether your income is likely to decline is required

• Almost done! Just a few more questions.

  Debts

  Do you currently owe any debts? *

  Yes No

  Whether you have any debts is required

  Debt 1

  Debt Type

  Select Installment Revolving Mortgage

  Creditor Name

  Interest Rate

  Present Balance

  Monthly Payment

  Owed By

  Applicant Joint ApplicantAuthorized User

  Debt 2

  Debt Type

  Select Installment Revolving Mortgage

  Creditor Name

  Interest Rate

  Present Balance

  Monthly Payment

  Owed By

  Applicant Joint ApplicantAuthorized User

  Debt 3

  Debt Type

  Select Installment Revolving Mortgage

  Creditor Name

  Interest Rate

  Present Balance

  Monthly Payment

  Owed By

  Applicant Joint ApplicantAuthorized User

  Debt 4

  Debt Type

  Select Installment Revolving Mortgage

  Creditor Name

  Interest Rate

  Present Balance

  Monthly Payment

  Owed By

  Applicant Joint ApplicantAuthorized User

  Totals

  Present Balance

  Monthly Payment
• Step 13

  Property Owned

  Which of these assets do you own?

  Home Vehicle 1 Vehicle 2

  Home

  Date Purchased

  Purchase Price

  Current Market Value

  In whose name

  Vehicle 1

  Year, Make & Model

  Financed By

  Balance Owning

  Monthly Payment

  Vehicle 2

  Year, Make & Model

  Financed By

  Balance Owing

  Monthly Payment
• Step 14

  Please provide a reference

  Examples of valid references: a relative, a colleague, a supervisor, or a community leader who knows you well.

  If your reference is a relative, it must be a relative not living with you.

  Type of Reference *

  Reference Name *

  Reference Phone Number *

  Reference Address *

  Reference Address Line 2

  Reference City

  Reference State *

  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Reference Zip *
• Step 15

  Final Questions and Agreement

  Do you have any outstanding judgments? *

  Yes No

  Whether you have outstanding judgments is required

  Have you ever filed for bankruptcy or had a debt adjustment plan confirmed under Chapter 13?*

  Yes No

  Chapter 13 Status is required

  Have you had property foreclosed upon or repossessed in the last 7 years?*

  Yes No

  Whether your property has been foreclosed is required

  Are you a U.S. Citizen or permanent resident alien? *

  Yes No

  Citizenship Status is required

  Are you liable for alimony, child support or maintenance programs? *

  Yes No

  Child Support Status is required

  What is the monthly payment *

  I/We agree to the terms and conditions of the Membership and Account Agreement, Truth-in-Savings Disclosure, Funds availability Policy Disclosure, if applicable, and to any amendment the Credit Union makes from time to time which are incorporated herein. I/We acknowledge receipt of a copy of the agreements and disclosures applicable to the accounts and services requested herein. If an access card or EFT service is requested and provided, I/we agree to the terms of and acknowledge receipt of the Electronic Fund Transfers Agreement and Disclosure. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

  Primary Applicant Date *

  Joint Applicant Authorized User Date *