Online Credit Card Request

Do you currently have a membership or account(s) with County-City Credit Union? *

Yes

How do you qualify for membership? *

I live in Jefferson County, WI (or in Watertown, Whitewater or Cambridge)

I work in Jefferson County, WI (or in Watertown, Whitewater or Cambridge)

I am the immediate Family of an Existing Member

None of the Above

Enter the name of your immediate family member who is a member of County-City Credit Union, and how they are related to you: *

Applicant Name (First, MI, Last) *

Social Security / Tax ID Number *

Date of Birth *

Street Address *

City *

State *

Zip *

Phone Number 999-999-9999 *

Email Address *

Card Limit Requested *

Applicant Employment Income
Alimony, Child Support, or separate maintenance income need not be revealed if you do not choose to have it considered.

	Employer Name / Source	Gross Monthly Income ($)	Employment Start Date
Income Source:	Employer Name / Source	Gross Monthly Income ($)	Employment Start Date
Income Source:	Employer Name / Source	Gross Monthly Income ($)	Employment Start Date
Income Source:	Employer Name / Source	Gross Monthly Income ($)	Employment Start Date

Housing Obligations: Do you rent or own your home? *

Rent

Own

What is your Monthly Rent Payment? *

What is your Monthly Mortgage Payment? *

Does your mortgage payment include escrow for Property Tax? *

Yes

No - Enter Annual Property Tax Estimate: No - Enter Annual Property Tax Estimate:

Does your mortgage payment include escrow for Homeowner's Insurance? *

Yes

No - Enter Annual Homeowner's Insurance Estimate: No - Enter Annual Homeowner's Insurance Estimate:

Marital Status *

Unmarried (Single, Divorced, Widowed)

Married

Will there be a co-applicant for this credit card? *

Yes

No, I will be the only signer

Will there be a co-applicant for this credit card? *

Yes, my spouse

Yes, someone other than my spouse (spousal info is still required below)

No, I will be the only signer (spousal info is still required below)

Spouse's Name (First, MI, Last) *

Spouse's Social Security / Tax ID Number *

Spouse's Date of Birth *

Spouse's Employment Income
Alimony, Child Support, or separate maintenance income need not be revealed if you do not choose to have it considered.

	Employer / Source	Gross Monthly Income ($)	Employment Start Date
Income Source:	Employer / Source	Gross Monthly Income ($)	Employment Start Date
Income Source:	Employer / Source	Gross Monthly Income ($)	Employment Start Date
Income Source:	Employer / Source	Gross Monthly Income ($)	Employment Start Date

Acknowledgement Required: Notice for Married Applicants not Applying with Spouse

The credit being applied for, if granted, will be incurred in the interest of the marriage or family of the undersigned. 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.

Please sign if you are not applying for this account or loan with your spouse. *

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Co-Applicant Name *

Co-Applicant Social Security / Tax ID Number *

Co-Applicant Date of Birth *

Co-Applicant Employment Income
Alimony, Child Support, or separate maintenance income need not be revealed if you do not choose to have it considered.

	Employer / Source	Gross Monthly Income ($)	Employment Start Date
Income Source:	Employer / Source	Gross Monthly Income ($)	Employment Start Date
Income Source:	Employer / Source	Gross Monthly Income ($)	Employment Start Date
Income Source:	Employer / Source	Gross Monthly Income ($)	Employment Start Date

Marital Status of Co-Applicant *

Unmarried (Single, Divorced, Widowed)

Married - Please enter Spouse's Name: Married - Please enter Spouse's Name:

Acknowledgement Required: Notice for Married Co-Applicant not Applying with Spouse

The credit being applied for, if granted, will be incurred in the interest of the marriage or family of the undersigned. 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.

Co-Applicant sign here if not applying for this account or loan with your spouse. *

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Other Information *

	Yes	No
Are you a US Citizen or Permanent Resident Alien?	Yes	No
Have you ever filed for bankruptcy or had a debt adjustment plan confirmed under Chapter 13?	Yes	No
Do you have any outstanding judgments?	Yes	No
Have you had property foreclosed upon or repossessed in the last 7 years?	Yes	No
Is your income likely to decline in the next two years?	Yes	No
Are you a co-maker, co-signer, or guarantor on any loan not listed above?	Yes	No

Authorization

By signing or otherwise authenticating below, you promise everything you have stated in this application is correct to the best of your knowledge. You authorize the Credit Union to obtain credit reports in connection with this application for credit. You understand the Credit Union will rely on the information in this application and your credit report to make its decision. If you request, the Credit Union will tell you the name and address of any credit bureau from which it received a credit report on you. It is a crime to willfully and deliberately provide incomplete or incorrect information in this application.

By signing or otherwise authenticating below, you also agree to be contacted by phone or email.

Signature of Applicant * 🛈

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Signature of Co-Applicant *

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County-City Credit Union is an Equal Opportunity Lender and Federally Insured by NCUA.

Please click "Submit" below to submit your request. Thank you!