APPLICATION FORM

  Type of Visa:
Line of Credit requested: $
NOTICE: Married applicants may apply for a separate account. If you are applying for Individual Credit, complete the Applicant Section. Complete the Co-Signer Information about your spouse if you live in a community property state (AZ, CA, ID, LA, NM, TX, WA, WI), or if your spouse will use this account. Joint credit applicants should complete both sections.
Are you applying for Number of cards requested:
APPLICATION INFORMATION $7.50 application fee refunded upon approval. Please fax recent paystub to 215-788-0662
NAME SOCIAL SECURITY DATE OF BIRTH
ADDRESS CITY STATE ZIP
HOME TELEPHONE NO. WORK TELEPHONE NO.
EMPLOYER POSITION DATE HIRED
ADDRESS CITY STATE ZIP
PREVIOUS EMPLOYER EMPLOYED FROM TO
GROSS MONTHLY SALARY  $ OTHER INCOME*  $ SOURCE
BANK NAME(Checking) BANK NAME (Savings)
DO YOU: MONTHLY PAYMENT $ VALUE OF PROPERTY (If owned) $
NAME OF LANDLOAD OR MORTGAGE COMPANY HOW LONG THERE?
NAME OF NEAREST RELATIVE NOT LIVING WITH YOU RELATIONSHIP
ADDRESS CITY STATE ZIP
HOME TELEPHONE NO. EMAIL ADDRESS
HAVE PAST OR PRESENT SUITS, JUDGEMENTS, REPOSESSIONS, BANKRUPTCY, OR GARNISHMENTS.
(If yes give details on separate sheet.)
*Income from alimony, child support and maintenance payments need not be disclosed if applicant does not want the credit union to consider it in determining the applicant’s credit
JOINT CREDIT (If you are applying for Joint Credit, please have your Co-Signer complete this section and if employed, attach a recent pay stub.)
NAME SOCIAL SECURITY DATE OF BIRTH
ADDRESS CITY STATE ZIP
HOME TELEPHONE NO. WORK TELEPHONE NO.
EMPLOYER POSITION DATE HIRED
ADDRESS CITY STATE ZIP
GROSS MONTHLY SALARY  $ DO YOU: MONTHLY PAYMENT $
OTHER INCOME*  $ SOURCE
HAVE PAST OR PRESENT SUITS, JUDGEMENTS, REPOSESSIONS, BANKRUPTCY, OR GARNISHMENTS.
(If yes give details on separate sheet.)
*Income from alimony, child support and maintenance payments need not be disclosed if applicant does not want the credit union to consider it in determining the applicant’s credit worthiness.

By submitting this application you are confirming that you have read, and understand, the “Rates and Terms” and that 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 our agents to verify any information provided to us by you. You agree and understand that if you are approved, you are contractually liable according to the applicable terms in the VISA Cardholder Agreement, which will be provided to you upon approval, and the Federal Disclosure Statement in the “Rates and Terms” box. You also promise to pay all amounts charged to your account according to its terms.