Visa® Personal Credit Card Application

* Required Fields

Application Steps:

  1. Complete and submit the form online.
  2. We will contact you regarding the status of your application.

Type of Account Desired *
Joint
Individual

Applicant Information

Personal Information
First Name *
     MI
    
Last Name *
 Social Security Number *
Driver's License/State ID # *
 State of Issuance *
  
Telephone Number *
 Birthdate (Month/Day/Year) *
 E-mail Address *
# of Dependents *
    

Address
Street Address *
 City *
State *
 Zip Code *
Length of Residence *
 years  months
Housing Status *

Previous Address

*If residing at present address for less than two years, complete the following:
Former Street Address
 Former City
Former State
 Former Zip Code
Length of Residence
 years  months

Employment Information
Present Employer *
 Telephone Number *
Street Address *
 City *
State *
 Zip Code *
Position/Department *
 Length of Employment *
 years  months
Income *
 Per *

*If employed in current position for less than two years or if currently employed in more than one position, complete the following:
Previous Employer
Previous Street Address
 Previous City
Previous State
 Previous Zip Code
Previous Length of Employment
 years  months

Other Income

*Alimony, child support or separae maintenance income need not be disclosed if you do not wish to have it considered as a basis for repaying this obligation.
Source
 Gross Monthly Other Income

Nearest Relative (not living with you)
Name *
 Relationship *
 Telephone Number *
Street Address *
 City *
State *
 Zip Code *

Joint Applicant Information

Personal Information
First Name *
     MI
    
Last Name *
 Relationship *
Driver's License/State ID # *
 State of Issuance *
  
Social Security Number *
 Birthdate (Month/Day/Year) *
 E-mail Address *

Address
Street Address *
 City *
State *
 Zip Code *

Employment Information
Present Employer *
Street Address *
 City *
State *
 Zip Code *
Position/Department *
 Length of Employment *
 years  months
Income *
 Per *

Other Income

*Alimony, child support or separae maintenance income need not be disclosed if you do not wish to have it considered as a basis for repaying this obligation.
Source
 Gross Monthly Other Income

Bank Information

Complete the following information for all applicants.
Bank Name *
 Account Type
Checking    Savings    Loan		 Account # *
 Account # *
Bank Name
 Account Type
Checking    Savings    Loan		 Account #
 Account #
Have either of you ever filed for bankruptcy? *
Yes No

All Debts or Obligations

* All fields are required as applicable.
Creditor
(include credit cards)		 Current Credit Limit
 Purpose
 Balance Owing
 Monthly Payment
Add Additional
NOTICE TO ALL OHIO RESIDENTS: "THE OHIO LAWS AGAINST DISCRIMINATION REQUIRE THAT ALL CREDITORS MAKE CREDIT EQUALLY AVAILABLE TO ALL CREDIT WORTHY 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.

Acknowledgement
*

I (We) apply for a Visa card or cards and herby request that a card or cards and related Personal Identification Number be issued to me (us). In consideration of the issuance of such card(s), I (we) agree to be bound by the terms and conditions delivered upon approval of card(s) as they may be revised from time to time. If more than one person signs this application and agreement, such person will be liable jointly and severally on all Visa account and, in the event of the issuance of such card(s), each person will be deemed to be a Visa "cardholder" and to authorize the other person(s) to use such card(s). I (we) certify that the information provided above is true and accurate to the best of my (our) knowledge and authorize the issuer to obtain any credit information concerning me (us) that it requires in connection with this application. By signing below I acknowledge receipt of Citizens National Bank’s credit card disclosure and agree to the terms.

ALL PARTIES SIGNING THIS APPLICATION ARE AFFIRMING THEIR INTENT TO APPLY FOR JOINT CREDIT. A SINGLE SIGNATURE IMPLIES INTENT FOR INDIVIDUAL CREDIT.

Type your name(s) in the box below to represent your electronic signature. *
Applicant's Signature *
 Date *


 
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