Progress: Application> Confirmation> Decision

* Indicates Required Information
Primary Applicant Information
Prefix
First Name*
 MI
 Last Name*
 Suffix
Name Displayed on Card*
 Email Address
Social Security Number*
 		 Birth Date*
(yyyy)
Mother's Maiden Name*
 Primary Phone Number*
 Mobile Phone Number
Residential Street Address*
 Address Line 2
 City*
 State*
 Zip Code*
Time at Current Residence*
Years    Months 		Please choose housing situation*
 Drivers License Number*
 Drivers License State*
Are you a US Citizen or Permanent Resident?* Yes No
Current Employer Name*

(If Self Employed, please list your company name.)		 Time with Employer*
Years    Months 		Business Phone Number
Do you have a banking relationship with Jefferson County Medical Society?*  Yes No
Gross Annual Income*
$ .00		 Requested Credit Limit
$ .00

Co-Applicant Information (Optional)
Prefix
First Name
MI
 Last Name
Suffix
Name Displayed on Card
 Email Address
Social Security Number
 		 Birth Date
(yyyy)
Mother's Maiden Name
 Primary Phone Number
Mobile Phone Number
Please provide the co-applicant's address if it is different from the primary applicant's address.
Residential Street Address
Address Line 2
City
State
Zip Code
Time at Current Residence
Years    Months 		Please choose housing situation
 Drivers License Number
 Drivers License State
Current Employer Name

(If Self Employed, please list your company name.)		 Time with Employer
Years    Months 		Business Phone Number
Gross Annual Income
$ .00		 Requested Credit Limit
$ .00
Balance Transfer Information (optional)
Please continue to pay all creditors until your balance transfer request appears on your statement. If your balance transfer request exceeds your assigned credit line, we will elect to pay off creditors in the order in which they appear on your application. Each balance transfer request must be at least $250.

View Disclosures
1.  Name of Creditor
 Account Number

 Transfer Amount
$ .00
  Payment Address
 Address Line 2
 City
 State
 Zip Code
2.  Name of Creditor
 Account Number

 Transfer Amount
$ .00
  Payment Address
 Address Line 2
 City
 State
 Zip Code
3.  Name of Creditor
 Account Number

 Transfer Amount
$ .00
  Payment Address
 Address Line 2
 City
 State
 Zip Code
Add Authorized Users (optional)
1.  Prefix
First Name
 MI
 Last Name
 Suffix
Name Displayed on Card
 Relationship
  Social Security Number
 		 Birth Date
(yyyy)
Number of cards requested
2.  Prefix
First Name
 MI
 Last Name
 Suffix
Name Displayed on Card
 Relationship
  Social Security Number
 		 Birth Date
(yyyy)
Number of cards requested
3.  Prefix
First Name
 MI
 Last Name
 Suffix
Name Displayed on Card
 Relationship
  Social Security Number
 		 Birth Date
(yyyy)
Number of cards requested