|
Credit Card Application
167th TFR Federal Credit Union Credit Card
Application
Please print this form, fill it out and fax to 304.267.9476 |
| General Information |
Will you be applying
for Individual or Joint Credit:  Joint Individual |
| If applying for
joint credit, please sign below to verify that you intend to apply for joint credit |
| Applicant: |
Co-Applicant: |
Marital Status: Complete
marital status if this application is for:
a. Joint or secured credit, or
b. You reside in or rely on property located in a Community Property State. (AZ, CA, ID, LA, NM, NV, TX, WA, WI)
Unmarried
Married
Separated
This loan is not for joint or secured credit
and I do not live in the states listed above. |
| Type of Card
Requested: |
| Number of Cards Requested: |
Limit Requested: |
| Primary Applicant: |
| Last Name: |
Member Number: |
| First Name: |
Middle Name: |
| Social Security Number
(TIN): |
Date of Birth: |
| Number of Dependents: |
Ages of Dependents: |
| Home Phone Number: |
Work Phone Number: |
| Other Phone Number: |
Email Address: |
| Drivers License #: |
Drivers License State: |
| Mother's Maiden
Name: |
| Home
Address |
| Address 1: |
| Address 2: |
| City: |
State, Zip: |
| Time at Current Residence: |
Residence Type: Rent Own Other: |
| Monthly
Payment: |
| Previous
Address |
| Address 1: |
| Address 2: |
| City: |
State, Zip: |
| Time at Previous Residence: |
Residence Type: Rent Own Other: |
| Present
Employer |
| Name: |
Phone Number: |
| Employment
Status: Full Time Part Time Temp Retired Other (please specify): |
| Job Title: |
Job Start Date: |
| Gross Salary: |
per Year Month Hour |
| Alimony, child support, or
separate maintenance income need not be revealed
if you do not wish to have it considered as a basis for repaying this obligation. |
| Other Income: |
per Year Month Hour |
| Other Income Source: |
|
| Previous
Employer |
| Name: |
Phone Number: |
| Employment
Status: Full Time Part Time Temp Retired Other (please specify): |
| Job Title: |
Job Start Date: |
| Job End Date: |
|
| Gross Salary: |
per Year Month Hour |
| Co-Applicant: |
| Last Name: |
Member Number: |
| First Name: |
Middle Name: |
| Social Security Number: |
Date of Birth: |
| Number of Dependents: |
Ages of Dependents: |
| Home Phone Number: |
Work Phone Number: |
| Other Phone Number: |
Email Address: |
| Drivers License #: |
Drivers License State: |
| Home
Address |
| Address 1: |
| Address 2: |
| City: |
State, Zip: |
| Time at Current Residence: |
Residence Type: Rent Own Other: |
| Monthly
Payment: |
| Previous
Address |
| Address 1: |
| Address 2: |
| City: |
State, Zip: |
| Time at Previous Residence: |
Residence Type: Rent Own Other: |
| Present
Employer |
| Name: |
Phone Number: |
| Employment
Status: Full Time Part Time Temp Retired Other (please specify): |
| Job Title: |
Job Start Date: |
| Gross Salary: |
per Year Month Hour |
| Alimony, child support, or
separate maintenance income need not be revealed
if you do not wish to have it considered as a basis for repaying this obligation. |
| Other Income: |
per Year Month Hour |
| Other Income Source: |
|
| Previous
Employer |
| Name: |
Phone Number: |
| Employment
Status: Full Time Part Time Temp Retired Other (please specify): |
| Job Title: |
Job Start Date: |
| Job End Date: |
|
| Gross Salary: |
per Year Month Hour |
| Additional Information |
How would you prefer to be
contacted?
Home Phone
Work Phone
Other Phone
Email Address
Other: |
Special
Instructions/Comments:
|
| Signatures |
Income verification is required; other information may be
required.
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 Financial Institution, information concerning me or my affairs.(Sec. 1014, Title 18, U.S.
Code makes it a Federal Crime to knowingly make a false statement on this application.)
|
| Primary Applicant Signature: |
Date: |
| Co-Applicant Signature: |
Date: |
|
|
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