**PLEASE COMPLETE ALL APPLICABLE FIELDS**

* Required Field
  Will there be a co-applicant on this VISA application?

  Type of card requested
  Account Type

  Credit Limit Requested

Account Holder/Primary Applicant

* Owner Name
* Account #
* Social Security Number - -
* Address
* City
* State
* Zip Code
* Home Phone() -
  Work Phone() - ext
* Driver's License
  Mother's Maiden Name
  Employer Name
  Employer Phone Number() -
  Start Date / / (mm/dd/yyyy)
  Gross Income (Annual)
  Net Monthly Pay
  Job Title

Joint Account Holder/Joint Applicant

If this is a joint account, please fill out the section below.

  Joint Name:
  Account #
  Social Security Number - -
  Address
  City
  State
  Zip Code
  Home Phone() -
  Work Phone() - ext
  Driver's License
  Mother's Maiden Name
  Employer Name
  Employer Phone Number() -
  Start Date / / (mm/dd/yyyy)
  Gross Income (Annual)
  Net Monthly Pay
  Job Title

Debts / Monthly Payments

 Type of PaymentMonthly Amount
1. Rent or Mortgage
2.Credit Card
3.
4.
5.
6.
7.
8.
9.

In addition to Rent/Mortgage, list all other debts (for example, auto loans, credit cards, second mortgage, home association dues, alimony, child support, child care, medical utilities, auto insurance, IRS liabilities, etc.). Please use a separate line for each credit card and auto loan.


Accounts

 Account NumberFinancial Institution
Checking/Share Draft
Savings

Names of 2 references not living with you

 NameAddressRelationship
Reference #1
Reference #2


  Are you a co-borrower, co-signer, endorser or guarantor on any loan or contract?

  If yes, for whom?
  If yes, to whom?
  Are there any unsatisfied judgements against you?

  If yes, amount owed?
  If yes, owed to whom?
  Have you ever had a car or other personal property repossessed by a creditor, filed for bankruptcy, or been party to a wage assignment or collection suit?

Please note: Income verification is required; other information may be required.

Please email, fax, or mail two latest pay stubs to the attention of VISA Department when you submit this application.

Alimony, child support, or separate maintenance income need not be listed unless you choose to have such income considered regarding extension and repayment of the credit requested.

I certify that statements on this application are true and complete. I authorize any person, association, firm, or corporation to furnish, on request of this Credit Union, information concerning me or my affairs.

By clicking the submit button I acknowledge that I have read the Visa Terms and Conditions, and Agreements & Disclosures.

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Equal Housing LenderNational Credit Union Administration
NCUA - Your savings federally insured to at least $250,000 and backed by the full faith and credit of the United States Government. National Credit Union Administration, a U.S. Government agency. Equal Housing Lender - We do business in accordance with the Fair Housing Law and Equal Opportunity Credit Act