Visa Application

VISA CREDIT CARD APPLICATION

Complete all the questions, or answer N/A.

TYPE OF CARD APPLIED FOR

Classic

Secured Classic

Platinum

Requested Credit Limit *

Member Account Number *

Email *

Phone Number *

First Name *

Last Name *

Social Security Number *

Date of Birth *

Mothers Maiden Name *

Address *

City *

ZIP Code *

Previous Address if Less Than 2 Years

City

ZIP Code

Current Employer *

Employer Address *

Employer City *

Enter ZIP Code *

Employer Phone Number *

Job Start Date *

Job Title *

Monthly Gross Income *

Other Income

(Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as basis for repaying this obligation.)

Submit Paystub or Tax Returns (Optional-We may request upon approval)

Click or drag & drop file here to upload

Home

Own

Rent

Lease

Other

Mortgage/Rent Payment *

Name and Phone # of Nearest Relative Not Living With You *

Co-Applicant First Name

Co-Applicant Last Name

Co-Applicant Address

Co-Applicant City

Co-Applicant ZIP Code

Co-Applicant Social Security Number

Co-Applicant Date of Birth

Co-Applicant Phone Number

Co-Applicant Email

Co-Applicant Current Employer

Co-Applicant Employer Address

Co-Applicant Employer City

Enter ZIP Code

Co-Applicant Job Start Date

Co-Applicant Job Title

Co-Applicant Employer Phone Number

Co-Applicant Monthly Gross Income

Co-Applicant Other Income

(Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as basis for repaying this obligation.)

Co-Applicant Submit Paystub or Tax Returns (Optional-We may request upon approval)

Click or drag & drop file here to upload

Co-Applicant Previous Address if Less Than 2 Years

City

ZIP Code

Co-Applicant Home

Own

Rent

Lease

Other

Co-Applicant Mortgage/Rent Payment

Co-Applicant Name & Phone # of Nearest Relative Not Living With You

Agreement and Disclosures

You warrant the truth of the above information and You realize that it will be relied upon by Us in deciding whether or not to grant the credit applied for. You hereby authorize Us, Our employees and agents to investigate and verify any information provided to Us by You. You agree and understand that if approved, You are contractually liable according to the applicable terms of the Credit Card Agreement and Disclosure. You will receive a copy of that Disclosure no later than the time of Your first credit advance and You promise to pay all amounts charged to Your Account according to its terms. If this is a joint application, You agree that such liability is joint and several. You authorize Us to accept Your facsimile signatures on this application and agree that Your facsimile signature will have the same legal force and effect as Your original signature. You assume any risk that may be associated with permitting Us to accept Your facsimile signature.

You grant and consent to a lien on Your share with Us (except IRA and Keogh accounts) and any dividends due or to become due to You from Us to the extent You owe on any unpaid Credit Card balance.

Primary Applicant *

I acknowledge and agree that all information above is accurate and that I have read and agree to the terms and conditions of the Visa Credit Card Agreement and Disclosures below.

Co-Applicant

I acknowledge and agree that all information above is accurate and that I have read and agree to the terms and conditions of the Visa Credit Card Agreement and Disclosures below.

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Mobile Phone

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