SECURE ONLINE APPLICATION

VISA CREDIT CARD APPLICATION

General Information

Type of Application:

Applying for individual or joint credit?

Marital Status:

* Credit Limit Requested $

* Term Requested


Primary Applicant

* Member Number

* Name

*Social Security Number (TIN)

*Date of Birth

Number of Dependents

Age of Dependents

*Home Phone Number

Work Phone Number

Cell Phone Number

Email Address

Drivers License Number

Drivers License State

Mothers Maiden Name

Home Address

*Address (Include both physical and PO Box if applicable)

*City

State

*Zip

Time at Current Residence

Residence Type

Monthly Payment $

Present Employer

Name

Phone Number

Employment Status

Job Title

Job Start Date

Gross Salary

Other Income

Other Income Source


Co-Applicant

Member Number

Name:

Social Security Number (TIN)

Date Of Birth

Number of Dependents

Age of Dependents

Home Phone

Work Phone

Cell Phone

Email Address

Drivers License #

Drivers License State

Home Address

Address (Include both physical and PO Box if applicable)

City

State

Zip

Time at Current Residence

Residence Type

Monthly Payment $

Present Employment

Name

Phone Number

Job Title

Employment Status

Gross Salary

Other Income

Other Income Source


References
Nearest Relative Not Living With You

Name:

Relationship

Phone Number

Address

City

State

Zip

Debts/Monthly Payments

List all other debts (auto loans, credit cards, second mortgage, home assoc. dues, alimony, child support, child care, medical, utilities, auto insurance, IRS liabilities, etc) ... please include monthly payment amounts.


Additional Information

How would you prefer to be contacted?

Special Instructions/Comments

 


By checking this box, 1. You promise that everything you have stated in this application is correct to the best of your knowledge and that the above information is a complete listing of what you owe. If there are any important changes you will notify us in writing immediately. You authorize the Credit Union to obtain credit reports in connection with this application for credit and for any update, increase, renewal, extension or collection of the credit received. You understand that the Credit Union will rely on the information in this application and your credit report to make its decision. If you request, the Credit Union will tell you the name and address of any credit bureau from which it received a credit report on you. It is a federal crime to willfully and deliberately provide incomplete or incorrect information on loan applications made to federal credit unions or state chartered credit unions insured by NCUA.

2. If you are applying for a credit card, you understand that the use of your card will constitute acknowledgment of receipt and agreement to the terms of the credit card agreement and disclosures. You grant us a security interest in all individual and joint share and/or deposit accounts you have with us now and in the future to secure your credit card account. When you are in default, you authorize us to apply the balance in these accounts to any amounts due. Shares and deposits in an Individual Retirement Account, and any other account that would lose special tax treatment under state or federal law if given as security, are not subject to the security interest you have given in your shares and deposits.

This credit union is federally insured by the National Credit Union Administration.
Copyright 2011 Community Credit Union of Southern Humboldt. All Rights Reserved!