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Instructions for this application:
Please print out this application and mail or fax it to SRNYFCU.
Click here to find the locations and phone numbers
VISA CREDIT CARD APPLICATION Self Reliance Account Number ___________
| LAST NAME:_____________________ | FIRST NAME:_____________________ | |
| Social Security Number:_____________________ | Date of Birth: |
_____________ Month Day Year |
Drivers License & State _____________________
| Home Address: | ____________________________ Street Address Apartment Number |
Payment Amount________ | ÿ Own ÿ Rent |
| ____________________________ City, State, Zip |
Years at this address _____ | ||
Home Phone:___________________________________
Previous Address if less than
| 2 years at present address: | ___________________________ | ÿ Own ÿ Rent |
| ___________________________ | Years there_______ |
Number of Dependents____________
Present Employer __________________________________________________
Employer Address ___________________________________________________
Business Phone __________________________________________________
| Position _______________________ | Date Hired _____________________ |
Joint applicant’s Last Name (If applicable) __________________________________
First Name __________________________________
Co-applicant’s Social Security No. __________________________
Date of birth __________________________
Driver’s License & State _____________________
Employer __________________________
Employer Address ____________________________________________________
Position ___________________________
Date Hired ___________________________
Business Phone ___________________________
Monthly Salary Gross ______________ Other Income: _______________
Net ______________ ______________________________
| Debts | Monthly Payment |
| __________________________ | ____________________ |
| ___________________________ | ____________________ |
| ___________________________ | ____________________ |
| ___________________________ | ____________________ |
In addition to Rent/Mortgage, list all other debts (for example, auto loans, credit cards, second mortgage, home association dues, alimony, child support, child care, medical utilities, auto insurance, IRS liabilities, etc.
PLEASE NOTE: Income verification is required; other information may be required.
Alimony, child support, or separate maintenance income need not be listed unless you choose to have such income considered regarding extension and repayment of the credit requested.
This statement is submitted to obtain credit and I/we certify that all information herein is true and complete. I/we also authorize the Credit Union to verify or obtain further information the Credit Union may deem necessary concerning my/our credit standing if this application is approved and a VISA card(s) is issued. The undersigned applicant(s) by signing, using or permitting another to use the VISA card(s) agree(s) that the applicants will be bound by the same terms and conditions of the cardholder agreement accompanying the VISA card(s) and all amendments. (Sec. 1014, Title 13, U.S. Code, makes it a Federal Crime to knowingly make a false statement on this application of a Federal Credit Union.)
A COPY OF A PAY STUB FROM YOUR EMPLOYER(S) MUST ACCOMPANY THIS APPLICATION. THANK YOU!
Individual Signature ___________________________________ Date ____________
Joint Name __________________________ Joint Soc. Sec. # ____________
Joint Signature _____________________________________________________
