Personal Credit Card ApplicationServicesPersonal Credit Card Application 1. Type & Card Choice Type of Account Requested IndividualJointVISA ClassicVISA Gold Choice of Card Design Scottsbluff National MonumentTetons (Note Gold Design is shadow print only) 2. Applicant Full Name Date of Birth Social Security Number Home Phone Present Address City State Zip How Long at Address Years Months Own or Rent OwnRent No. of Dependents Previous Address City State Zip Present Employer Name Present Employer Phone Number Present Occupation Present Employer Address City Employer State Zip How Long at Present Employer Years Months Name of Nearest Relative Relative Phone Address of Nearest Relative City Relative State Zip Email Address Confirm Email Address 3. Co-Applicant Full Name Social Security Number Home Phone Present Street Address City State Zip 4. Assets Cash (List Name of Institution) Amount CD's, Bonds and Etc. Amount Stocks Amount Cash Value of Life Insurance Amount Home Amount LiabilitiesList Name of Creditors and Account Numbers Liability Monthly Payments Liability Monthly Payments Liability Monthly Payments Liability Monthly Payments Liability Monthly Payments Liability Monthly Payments Liability Monthly Payments Liability Monthly Payments Liability Monthly Payments Liability Monthly Payments Mortgage/ Rent Payments TOTAL 5. IncomeApplicant Annual Income Salary* Amount Commissions or Bonus Dividends and Interest Alimony, child support or maintenance (you need not show this unless you wish it considered) Other Income - List Source TOTAL 5b. IncomeCo-Applicant Annual Income Salary Amount Commissions or Bonus Dividends and Interest Alimony, child support or maintenance (you need not show this unless you wish it considered) Other Income - List Source TOTAL 6. Balance Transfer Take advantage of your low interest rate by transferring balances from your higher rate cards to your new Platte Valley Visa account. Simply fill out the information below and sign the authorization, and we will transfer the amount listed to your new Platte Valley Visa account. What's more, there's absolutely no fee for this service. We'll handle all the paperwork - you pocket the interest savings. (Please remember, the total amount transferred may not exceed your credit line.) Please continue to pay any monthly statements you receive from the issuers listed on this form until you receive a statement showing no further balance is due. Bank/Card Issuer Payment Address Account Number Amount to Transfer 7. Agree and Submit I(the applicant) agree that all of the information on this page is correct and up to date.
