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&

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CREDIT APPLICATION
VISA® CLASSIC & VISA® GOLD

CHECK CARD OF CHOICE:

  VISA® Gold
  VISA® Classic
  Limit Increase

CHECK ACCOUNT CHOICE: (Select Only One)
I/WE ARE APPLYING FOR:

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  INDIVIDUAL CREDIT - relying solely on my income or assets.
  INDIVIDUAL CREDIT - relying on my income or assets as well 

                 as income or assets from other sources.

e

r

e
.

CREDIT LIMIT REQUESTED $__________
*If applicant does not qualify for a VISA® Gold, a VISA® Classic may be substituted.

  JOINT CREDIT - We intend to apply for joint credit. (Initials) _______ _______

IMPORTANT APPLICANT INFORMATION: Federal law requires financial institutions to obtain sufficient information to verify your identity. You may be asked several questions and to 
provide one or more forms of identification to fulfill this requirement. In some instances we may use outside sources to confirm the information. The information you provide is protected 
by our privacy policy and federal law.

APPLICANT Note: All Sections Should be Filled Out Completely. If Not, Processing Of Your Application May Be Delayed.

Last Name 

                                                                            First                                                                                 Middle   

                             Social Security #

Date of Birth 

                     No. of Dependents 

Home Telephone 

 Own  

 Rent  

 Other 

                             Mo. Payments $

Drivers License# and State                                                                                     Cell Phone 

                                       E-mail

Street Address 

Employment 

Address 

Name and Address of Previous Employer 

Source of Additional Income* 

                                 City                                                               State                               Zip Code                                 How Long (yrs)

                         Self Employed?   

 Yes   

 No                     Telephone Number   

    How Long (yrs)

Position/Occupation 

                             Monthly Gross Income

    How Long (yrs)

    Amount per Month $

Nearest Relative (Not Living With You) 

Telephone Number 

                             Relationship

Relative’s Address                                                                                                 City 

                               State 

    Zip Code

* You need not furnish alimony, child support or maintenance information, if you do not want us to consider it in evaluating your application.

JOINT APPLICANT (If applying for a joint account)

Last Name 

                                                                            First 

            Middle   

                             Social Security #

Date of Birth 

                     No. of Dependents 

Home Telephone 

 Own  

 Rent  

 Other 

                             Mo. Payments $

Drivers License# and State                                                                                     Cell Phone 

                                       E-mail

Street Address 

Employment 

Address 

Name and Address of Previous Employer 

Source of Additional Income* 

                                  City                                                              State                               Zip Code                                 How Long (yrs)

                         Self Employed?   

 Yes   

 No                     Telephone Number   

    How Long (yrs)

Position/Occupation 

                             Monthly Gross Income

    How Long (yrs)

Amount  per Month $

* You need not furnish alimony, child support or maintenance information, if you do not want us to consider it in evaluating your application.

CREDIT INFORMATION Attach additional sheet if necessary

Bank Name and Address 

       Branch 

                                           Loans    

  Open 

  Closed

Checking Account Number/Name Listed 

                                                                    Savings Account Number/Name Listed

NAME AND ADDRESS OF CREDITOR 

NAME UNDER WHICH ACCOUNT IS LISTED 

ACCOUNT NUMBER 

BALANCE 

MONTHLY PAYMENT

1. Automobile

2. Home Mortgage

3. Bank Credit Card/Bank Name & Address

4. Other

5.

6.

SIGNATURE(S)

$

$

$

$

$

$

$

$

$

$

$ 

$

PLEASE  READ  THE  FOLLOWING  CAREFULLY  BEFORE  SIGNING:  This  statement  is  submitted  to  obtain  credit  and  I/we  certify  that  all  information  herein  is  true  and  complete.  I/We 
agree that inquiries may be made to verify information and that credit references or verification may be given based on inquiries from other parties. This offer is subject to the credit policies of 
this institution. I/We agree to be bound by the terms and conditions of the bank card agreement, a copy of which will be mailed to the applicant if this application is granted, receipt of such 
agreement and acceptance of such terms to be conclusively presumed by the applicant’s use. If this is a joint application, the undersigned shall be jointly and severally liable for any and all 
credit extended from time to time.

X  __________________________________________________________________________    

         Applicant Signature 

         Date

X  __________________________________________________________________________    

         Co-Applicant Signature 

      Date

CREDIT DISCLOSURES

ANNUAL 
PERCENTAGE RATE 
FOR PURCHASES

ANNUAL PERCENTAGE
RATE FOR CASH ADVANCE 
& BALANCE TRANSFERS

ANNUAL
MEMBERSHIP 
FEE

METHOD OF 
COMPUTING
THE BALANCE
FOR PURCHASES

GRACE 
PERIOD

TELEPHONE
PAYMENT
FEE

LATE
PAYMENT
FEE

CASH 
ADVANCE 
FEE

BALANCE
TRANSFER
FEE

OVER
CREDIT
LIMIT 
FEE

LOST/
STOLEN
CARD 
FEE

MINIMUM
FINANCE
CHARGE

Gold

10.99%
15.99%

Classic

Gold

10.99%
15.99%

Classic

$0

AVERAGE DAILY
BALANCE
INCLUDING 
NEW
PURCHASES*

25
DAYS*

$10 PER
OCCURRENCE

$25

2% OF CASH

ADVANCE

TRANSACTION

($2 MINIMUM)

2% OF 
BALANCE 
TRANSFER 
AMOUNT

$0

$0

$0

The information listed above was accurate as of the REV date shown in the lower left-hand corner.
Because rates and terms are subject to change, you may contact us for the current information by writing to the business reply address shown on the reverse side.

*A Finance Charge will be imposed on Credit Purchases only if you elect not to pay the entire New Balance shown on your monthly statement for the previous billing cycle within 25 days from the closing 
date of that statement. If you elect not to pay the entire New Balance shown on your previous monthly statement within that 25-day period, a Finance Charge will be imposed on the unpaid average daily 
balance of such Credit Purchases from the previous statement closing date and on new Credit Purchases from the date of posting to your account during the current billing cycle, and will continue to accrue 
until the closing date of the billing cycle preceding the date on which the entire New Balance is paid in full or until the date of payment if more than 25 days from the closing date.

The Finance Charge for a billing cycle is computed by applying the monthly Periodic Rate to the average daily balance of Credit Purchases, which is determined by dividing the sum of the daily balances 
during the billing cycle by the number of days in the cycle. Each daily balance of Credit Purchases is determined by adding to the outstanding unpaid balance of Credit Purchases at the beginning of the 
billing cycle any new Credit Purchases posted to your account, and subtracting any payments as received and credits as posted to your account, but excluding any unpaid Finance Charges. VISA® cards 
may not be used for any illegal transaction.

FOR INTERNAL USE ONLY

VISA ACCOUNT #

DATE APPROVED     

CREDIT LINE 

APPROVED BY            

# CARDS 

PRO. CODE

REV. 11.09

Fold and secure with tape for mailing.

Member FDIC