Visa Credit Card Application

Loan Information

Applicant Information

Asset Information

Other Information

Disclosures and Signatures

* Indicates Required

Credit Card Information

Credit Limit Requested Requested ($) *

If Authorized User, Name

Application Type *

Individual Joint

Application Type is required

Is your Co-Applicant your spouse?*

Yes No

Whether your co-applicant is your spouse is required

Do you live in or is the property pledged as collateral located in a community property state (AK, AZ, CA, ID, LA, NM, NV, TX, WA, WI)*

Yes No

Whether you live or have collateral in a community property state is required

Will your spouse use the account?*

Yes No

Whether your spouse will use the account is required

Are you relying on your spouse's income as a basis for repayment?*

Yes No

Whether you are relying on your spouse's income for repayment is required

Are you relying on income from alimony, child support, or separate maintenance as a basis for repayment?*

Yes No

Whether you are relying on other income for repayment is required

Will this loan have a guarantor who is not your spouse or co-applicant?*

Yes No

Whether there is another guarantor is required

Applicant and Co-Applicant each agree and acknowledge the intent to apply for joint credit (sign below):

Primary Applicant Signature *

Clear Signature

Co-Applicant Signature *

Clear Signature

Date *

Date *

Payment Protection

Are you interested in having your loan protected?*

Yes No

Whether you are interested in having the loan protected is required
If you answer "yes", the credit union will disclose the cost to protect your loan. The protection is voluntary and does not affect your loan approval. In order for your loan to be covered, you will need to sign a separate application that explains the terms and conditions.
Applicant Information

Last Name *

First Name *

Middle Initial *

Account Number

Social Security Number *

Birth Date *

Email Address *

Phone Number *

Business Phone/Ext.

Driver's License Number

Drivers License State

Ages of Dependents

Present Address

Address *

Address Line 2

City *

State *

Zip *

Housing Type*

Length at Residence *

Last Previous Address:

Previous Address

Previous Address Line 2

Previous City

Previous State

Previous Zip

Housing Type

Length at Residence

Additional Information

Mortgage/Rent Owed to

Mortgage Balance

Monthly Payment

Interest Rate

Marital Status (Complete for Joint Credit, Secured Credit, or if you live in a community property state)

Married Separated Unmarried (Single/Divorced/Widowed)

Employment/Income

Start Date *

Employment Status *

Full Time Part Time

Employment Type is required

Employer Name *

Employer Address *

Employer City *

Employer State *

Employer Zip *

Employment Income *

Per *

Title/Grade *

If employed for less than 5 years at your current job:

Previous Employer Name

Previous Employer Address

Previous Employer City

Previous Employer State

Previous Employer Zip

Starting Date

Ending Date

Additional Income

Notice: Alimony, Child Support, or Separate Maintenance Income Need Not Be Revealed If You Do Not Choose To Have It Considered

Other Income

Per

Source

Military

Is duty station transfer expected during next year?
Yes No
Whether you served in the military is required

Where*

Ending/Separation Date*

Reference

Name and address of nearest relative not living with you

Reference Name *

Reference Address *

Reference Address Line 2

Reference City *

Reference State *

Reference Zip *

Relationship *

Home Phone *

Co-Applicant Information

Type of Applicant

Spouse Guarantor Other

Last Name *

First Name *

Middle Initial *

Account Number

Social Security Number *

Birth Date *

Email Address *

Phone Number *

Business Phone/Ext.

Driver's License Number

Drivers License State

Ages of Dependents

Present Address

Address *

Address Line 2

City *

State *

Zip *

Housing Type*

Length at Residence *

Last Previous Address:

Previous Address

Previous Address Line 2

Previous City

Previous State

Previous Zip

Housing Type

Length at Residence

Additional Information

Mortgage/Rent Owed to

Mortgage Balance

Monthly Payment

Interest Rate

Marital Status (Complete for Joint Credit, Secured Credit, or if you live in a community property state)

Married Separated Unmarried (Single/Divorced/Widowed)

Employment/Income

Start Date *

Employment Status *

Full Time Part Time

Employment Type is required

Employer Name *

Employer Address *

Employer City *

Employer State *

Employer Zip *

Employment Income *

Per *

Title/Grade *

If employed for less than 5 years at your current job:

Previous Employer Name

Previous Employer Address

Previous Employer City

Previous Employer State

Previous Employer Zip

Starting Date

Ending Date

Additional Income

Notice: Alimony, Child Support, or Separate Maintenance Income Need Not Be Revealed If You Do Not Choose To Have It Considered

Other Income

Per

Source

Military

Is duty station transfer expected during next year?
Yes No
Whether you served in the military is required

Where*

Ending/Separation Date*

Reference

Name and address of nearest relative not living with you

Reference Name *

Reference Address *

Reference Address Line 2

Reference City *

Reference State *

Reference Zip *

Relationship *

Home Phone *

Spouse Information

Type of Applicant

Co-Applicant Guarantor Other

Last Name *

First Name *

Middle Initial *

Account Number

Social Security Number *

Birth Date *

Email Address *

Phone Number *

Business Phone/Ext.

Driver's License Number

Drivers License State

Ages of Dependents

Present Address

Address *

Address Line 2

City *

State *

Zip *

Housing Type*

Length at Residence *

Last Previous Address:

Previous Address

Previous Address Line 2

Previous City

Previous State

Previous Zip

Housing Type

Length at Residence

Additional Information

Mortgage/Rent Owed to

Mortgage Balance

Monthly Payment

Interest Rate

Marital Status (Complete for Joint Credit, Secured Credit, or if you live in a community property state)

Married Separated Unmarried (Single/Divorced/Widowed)

Employment/Income

Start Date *

Employment Status *

Full Time Part Time

Employment Type is required

Employer Name *

Employer Address *

Employer City *

Employer State *

Employer Zip *

Employment Income *

Per *

Title/Grade *

If employed for less than 5 years at your current job:

Previous Employer Name

Previous Employer Address

Previous Employer City

Previous Employer State

Previous Employer Zip

Starting Date

Ending Date

Additional Income

Notice: Alimony, Child Support, or Separate Maintenance Income Need Not Be Revealed If You Do Not Choose To Have It Considered

Other Income

Per

Source

Military

Is duty station transfer expected during next year?
Yes No
Whether you served in the military is required

Where*

Ending/Separation Date*

Reference

Name and address of nearest relative not living with you

Reference Name *

Reference Address *

Reference Address Line 2

Reference City *

Reference State *

Reference Zip *

Relationship *

Home Phone *

Guarantor/Other Information

If you are relying on income from alimony, child support, or separate maintenance, complete this section to the extent possible about the person on whose payments you are relying.

Type of Applicant

Spouse Co-Applicant Guarantor Other

Last Name *

First Name *

Middle Initial *

Account Number

Social Security Number *

Birth Date *

Email Address *

Phone Number *

Business Phone/Ext.

Driver's License Number

Drivers License State

Ages of Dependents

Present Address

Address *

Address Line 2

City *

State *

Zip *

Housing Type*

Length at Residence *

Last Previous Address:

Previous Address

Previous Address Line 2

Previous City

Previous State

Previous Zip

Housing Type

Length at Residence

Additional Information

Mortgage/Rent Owed to

Mortgage Balance

Monthly Payment

Interest Rate

Marital Status (Complete for Joint Credit, Secured Credit, or if you live in a community property state)

Married Separated Unmarried (Single/Divorced/Widowed)

Employment/Income

Start Date *

Employment Status *

Full Time Part Time

Employment Type is required

Employer Name *

Employer Address *

Employer City *

Employer State *

Employer Zip *

Employment Income *

Per *

Title/Grade *

If employed for less than 5 years at your current job:

Previous Employer Name

Previous Employer Address

Previous Employer City

Previous Employer State

Previous Employer Zip

Starting Date

Ending Date

Additional Income

Notice: Alimony, Child Support, or Separate Maintenance Income Need Not Be Revealed If You Do Not Choose To Have It Considered

Other Income

Per

Source

Military

Is duty station transfer expected during next year?
Yes No
Whether you served in the military is required

Where*

Ending/Separation Date*

Reference

Name and address of nearest relative not living with you

Reference Name *

Reference Address *

Reference Address Line 2

Reference City *

Reference State *

Reference Zip *

Relationship *

Home Phone *
What you Owe

Debt 1

Debt Type

Creditor Name other than this credit union

Interest Rate

Present Balance

Monthly Payment

Owed By

Applicant Co-Applicant Spouse Other

Debt 2

Debt Type

Creditor Name other than this credit union

Interest Rate

Present Balance

Monthly Payment

Owed By

Applicant Co-Applicant Spouse Other

Debt 3

Debt Type

Creditor Name other than this credit union

Interest Rate

Present Balance

Monthly Payment

Owed By

Applicant Co-Applicant Spouse Other

Debt 4

Debt Type

Creditor Name other than this credit union

Interest Rate

Present Balance

Monthly Payment

Owed By

Applicant Co-Applicant Spouse Other

Debt 5

Debt Type

Creditor Name other than this credit union

Interest Rate

Present Balance

Monthly Payment

Owed By

Applicant Co-Applicant Spouse Other

Debt 6

Debt Type

Creditor Name other than this credit union

Interest Rate

Present Balance

Monthly Payment

Owed By

Applicant Co-Applicant Spouse Other

Debt 7

Debt Type

Creditor Name other than this credit union

Interest Rate

Present Balance

Monthly Payment

Owed By

Applicant Co-Applicant Spouse Other

Debt 8

Debt Type

Creditor Name other than this credit union

Interest Rate

Present Balance

Monthly Payment

Owed By

Applicant Co-Applicant Spouse Other

Debt 9

Debt Type

Creditor Name other than this credit union

Interest Rate

Present Balance

Monthly Payment

Owed By

Applicant Co-Applicant Spouse Other

Debt 10

Debt Type

Creditor Name other than this credit union

Interest Rate

Present Balance

Monthly Payment

Owed By

Applicant Co-Applicant Spouse Other

Debt 11

Debt Type

Creditor Name other than this credit union

Interest Rate

Present Balance

Monthly Payment

Owed By

Applicant Co-Applicant Spouse Other

Debt 12

Debt Type

Creditor Name other than this credit union

Interest Rate

Present Balance

Monthly Payment

Owed By

Applicant Co-Applicant Spouse Other

Totals

Present Balance

Monthly Payment

List any names under which your credit references and credit history can be checked:

What you Own

Asset 1

Asset Description

Market Value ($)

List location of property or financial institution

Pledged as collateral for another loan

Yes No

Owned By

Applicant Co-Applicant Spouse Other

Asset 2

Asset Description

Market Value ($)

List location of property or financial institution

Pledged as collateral for another loan

Yes No

Owned By

Applicant Co-Applicant Spouse Other

Asset 3

Asset Description

Market Value ($)

List location of property or financial institution

Pledged as collateral for another loan

Yes No

Owned By

Applicant Co-Applicant Spouse Other

Asset 4

Asset Description

Market Value ($)

List location of property or financial institution

Pledged as collateral for another loan

Yes No

Owned By

Applicant Co-Applicant Spouse Other

Asset 5

Asset Description

Market Value ($)

List location of property or financial institution

Pledged as collateral for another loan

Yes No

Owned By

Applicant Co-Applicant Spouse Other

Asset 6

Asset Description

Market Value ($)

List location of property or financial institution

Pledged as collateral for another loan

Yes No

Owned By

Applicant Co-Applicant Spouse Other

Asset 7

Asset Description

Market Value ($)

List location of property or financial institution

Pledged as collateral for another loan

Yes No

Owned By

Applicant Co-Applicant Spouse Other
Other Information About You (Applicant)

Are you a U.S. Citizen or permanent resident alien? *

Yes No

Citizenship Status is required

Do you have any outstanding judgments or have you ever filed for bankruptcy, had a debt adjustment plan confirmed under chapter 13, had property foreclosed upon or repossessed in the last 7 years, or been a party in a lawsuit? *

Yes No

Whether you have outstanding judgments is required
Please Explain *

Is your income likely to decline in the next two years? *

Yes No

Whether your income is likely to decline is required
Please Explain *

Are you a co-maker, co-signer or guarantor on any loan not listed above? *

Yes No

Co-Maker Status is required

For Whom (Name of Others Obligated on Loan)*

To Whom (Name of Others Obligated on Loan)*

Further Explanation

Other Information About You (Co-Applicant)

Are you a U.S. Citizen or permanent resident alien? *

Yes No

Citizenship Status is required

Do you have any outstanding judgments or have you ever filed for bankruptcy, had a debt adjustment plan confirmed under chapter 13, had property foreclosed upon or repossessed in the last 7 years, or been a party in a lawsuit? *

Yes No

Whether you have outstanding judgments is required
Please Explain *

Is your income likely to decline in the next two years? *

Yes No

Whether your income is likely to decline is required
Please Explain *

Are you a co-maker, co-signer or guarantor on any loan not listed above? *

Yes No

Co-Maker Status is required

For Whom (Name of Others Obligated on Loan)*

To Whom (Name of Others Obligated on Loan)*

Further Explanation

Other Information About You (Spouse)

Are you a U.S. Citizen or permanent resident alien? *

Yes No

Citizenship Status is required

Do you have any outstanding judgments or have you ever filed for bankruptcy, had a debt adjustment plan confirmed under chapter 13, had property foreclosed upon or repossessed in the last 7 years, or been a party in a lawsuit? *

Yes No

Whether you have outstanding judgments is required
Please Explain *

Is your income likely to decline in the next two years? *

Yes No

Whether your income is likely to decline is required
Please Explain *

Are you a co-maker, co-signer or guarantor on any loan not listed above? *

Yes No

Co-Maker Status is required

For Whom (Name of Others Obligated on Loan)*

To Whom (Name of Others Obligated on Loan)*

Further Explanation

Other Information About You (Guarantor/Other)

Are you a U.S. Citizen or permanent resident alien? *

Yes No

Citizenship Status is required

Do you have any outstanding judgments or have you ever filed for bankruptcy, had a debt adjustment plan confirmed under chapter 13, had property foreclosed upon or repossessed in the last 7 years, or been a party in a lawsuit? *

Yes No

Whether you have outstanding judgments is required
Please Explain *

Is your income likely to decline in the next two years? *

Yes No

Whether your income is likely to decline is required
Please Explain *

Are you a co-maker, co-signer or guarantor on any loan not listed above? *

Yes No

Co-Maker Status is required

For Whom (Name of Others Obligated on Loan)*

To Whom (Name of Others Obligated on Loan)*

Further Explanation

Consent to Contact

By executing this application, you agree we and/or our third party providers, including debt collectors, may contact you by telephone or text message at any telephone number associated with your account, including wireless telephone numbers (i.e. cell phone numbers) which could result to charges to you, in order to service your account or collect any amounts owed to us, excluding any contacts for advertising or telemarketing purposes as prescribed by law. You further agree methods of contact may include use of pre-recorded or artificial voice messages, and/or use of an automatic dialing device. You may withdraw consent to be contacted on your wireless telephone number(s) at any time by written notice to us at 506 W. Fairchild Street, Danville IL 61832, via phone at 217-442-9005 or 1-800-533-5615 or by any other reasonable means. If you have provided a wireless telephone number(s) on or in connection with any account, you represent and agree you are the wireless subscriber or customary user with respect to the wireless telephone number(s) provided and have the authority to give this consent. Furthermore, you agree to notify us of any change to the wireless telephone number(s) which you have provided to us.

State Law Notice(s)

Notice to Nebraska Residents

A credit agreement must be in writing to be enforceable under Nebraska law. To protect you and us from any misunderstandings or disappointments, any contract, promise, undertaking, or offer to forebear repayment of money or to make any other financial accommodation in connection with this loan of money or grant or extension of credit, or any amendment of, cancellation of, waiver of, or substitution for any or all of the terms or provisions of any instrument or document executed in connection with this loan of money or grant or extension of credit, must be in writing to be effective.

Notice to New York Residents

New York residents may contact the New York State Department of Financial Services to obtain a comparative listing of credit card rates, fees, and grace periods. New York State Department of Financial Services: 1-800-342-3736 or www.dfs.ny.gov.

Notice to Ohio Residents

The Ohio laws against discrimination require that all creditors make credit equally available to all creditworthy customers, and that credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio Civil Rights Commission administers compliance with this law.

Notice to Wisconsin Residents

(1) No provision of any marital property agreement, unilateral statement under section 766.59, or court decree under section 766.70 will adversely affect the rights of the Credit Union unless the Credit Union is furnished a copy of the agreement, statement, or decree, or has actual knowledge of its terms, before the credit is granted or the account is opened. (2) Please sign if you are not applying for this account or loan with your spouse. The credit being applied for, if granted, will be incurred in the interest of the marriage or family of the undersigned.

Signature for Wisconsin Residents Only

Clear Signature

Primary Applicant Date

Consensual Security Interest

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. Shares and deposits in an IRA or 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. You may withdraw these other shares unless you are in default. When you are in default, you authorize us to apply the balance in these accounts to any amounts due. For example, if you have an unpaid credit card balance, you agree we may use funds in your account(s) to pay any or all of the unpaid balance.

By signing or otherwise authenticating below, you are affirmatively agreeing that you are aware that granting a security interest is a condition for the credit card and you intend to grant a security interest. You acknowledge and agree that your pledge does not apply during any periods when you are a covered borrower under the Military Lending Act. For clarity, you will not be deemed a covered borrower, and your pledge will apply, if: (i) you become obligated on a credit transaction or establish an account for credit when you are not a covered borrower; or (ii) you cease to be a covered borrower.

Security Interest Acknowledgement and Agreement Primary Applicant Signature *

Clear Signature

Security Interest Acknowledgement and Agreement Co-Applicant Signature *

Clear Signature

Primary Applicant Date *

Co-Applicant Date *

Signatures

By signing or otherwise authenticating below:

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 recieved. You understand that the credit Union will tell you the name and address of any credit bureau from which it recieved a credit report on you. It is a crime to willfully and deliberately provide incomplete or incorrect information on this application.
If you are applying for a credit card, you understand the use of your card will constitute acknowledgment of receipt and agreement to the terms of the Consumer Credit Card Agreement and Disclosure.

Primary Applicant Signature *

Clear Signature

Co-Applicant Signature *

Clear Signature

Primary Applicant Date *

Co-Applicant Date *

How can we help?

Visa Credit Card Application

Credit Card Information

Payment Protection

Applicant Information

Present Address

Last Previous Address:

Additional Information

Employment/Income

If employed for less than 5 years at your current job:

Additional Income

Military

Reference

Co-Applicant Information

Present Address

Last Previous Address:

Additional Information

Employment/Income

If employed for less than 5 years at your current job:

Additional Income

Military

Reference

Spouse Information

Present Address

Last Previous Address:

Additional Information

Employment/Income

If employed for less than 5 years at your current job:

Additional Income

Military

Reference

Guarantor/Other Information

Present Address

Last Previous Address:

Additional Information

Employment/Income

If employed for less than 5 years at your current job:

Additional Income

Military

Reference

What you Owe

Debt 1

Debt 2

Debt 3

Debt 4

Debt 5

Debt 6

Debt 7

Debt 8

Debt 9

Debt 10

Debt 11

Debt 12

Totals

What you Own

Asset 1

Asset 2

Asset 3

Asset 4

Asset 5

Asset 6

Asset 7

Other Information About You (Applicant)

Other Information About You (Co-Applicant)

Other Information About You (Spouse)

Other Information About You (Guarantor/Other)

Consent to Contact

State Law Notice(s)

Notice to Nebraska Residents

Notice to New York Residents

Notice to Ohio Residents

Notice to Wisconsin Residents

Consensual Security Interest

Signatures