April 19, 2014
Platte Valley Bank VISA Application

VISA Credit Card Application

Indicates a required field.
1. Type & Card Choice Edit
  Individual       Joint       VISA Classic       VISA Gold
  Scottsbluff National Monument       Tetons (Note Gold Design is shadow print only)
Done


2. Applicant Edit
Years:     Months:    
  Own       Rent

(if less than 5 years at present address)
Years:     Months:    
Done



3. Co-Applicant Edit
Done



4. Assets Edit
Assets Amount Liabilities
List Name of Creditors and Account Numbers
Monthly Payments Balance
Cash (List Name of Institution):  
$
 
 
$
 
$
CD's, Bonds and Etc.:  
$
 
 
$
 
$
Stocks:  
$
 
 
$
 
$
Cash Value of Life Insurance:  
$
 
 
$
 
$
Home:  
$
 
 
$
 
$
     
 
$
 
$
     
 
$
 
$
     
 
$
 
$
     
 
$
 
$
     
 
$
 
$
Other Assets (Detail):
 
 
 
$
 
Mortgage/ Rent Payments
 
 
$
 
 
$
 
TOTAL
$  
TOTAL
$ $
Done



5. Income Edit
Annual Income Applicant Annual Income
Co-Applicant
Salary* $ Salary* $
Commissions or Bonus $ Commissions or Bonus $
Dividends and Interest $ Dividends and Interest $
Alimony, child support or maintenance
(you need not show this unless you wish it considered)
 
$
Alimony, child support or maintenance
(you need not show this unless you wish it considered)
 
$
Other Income - List Source
 
$
Other Income - List Source
 
$
 
TOTAL
$ TOTAL $
Done



6. Balance Transfer Edit
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.
Done



7. Agree and Submit
By clicking the agree box I/We certify that I am of legal age in the state in which I reside. I/We certify that the information provided is true and complete and agree to be bound by all the terms and conditions of the Cardholder Agreement and the Federal Truth in Lending Disclosures for the account which will be sent when the card is issued. I hereby authorize the Bank, or any credit bureau or other investigative agency employed by it, to investigate any information listed hereon or obtained from me or any other person pertaining to my financial responsibility. I understand that this offer is subject to a minimum household income of $9,600 and the request is for a Visa Classic account and certification of a satisfactory credit history or a minimum household account of $35,000 and the request is for a Visa Gold account and verification of a satisfactory credit history. See "Summary of Credit Terms" for important rate and fee information.
  Agree