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Confirmation
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Decision
* Indicates Required Information
Primary Applicant Information
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
First Name*
MI
Last Name*
Suffix
Jr
Sr
II
III
Name Displayed on Card*
Email Address*
Social Security Number*
Birth Date*
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
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12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
(yyyy)
Mother's Maiden Name*
Primary Phone Number*
Mobile Phone Number
Residential Street Address*
Address Line 2
City*
State*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip Code*
Time at Current Residence*
Years
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
30+
Months
0
1
2
3
4
5
6
7
8
9
10
11
Please choose housing situation*
Home Owner
Renter
Live with Parents
Other
Drivers License Number*
Drivers License State*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
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
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
30+
Months
0
1
2
3
4
5
6
7
8
9
10
11
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
Mr.
Mrs.
Miss
Ms.
Dr.
First Name
MI
Last Name
Suffix
Jr
Sr
II
III
Name Displayed on Card
Email Address
Social Security Number
Birth Date
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
(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
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip Code
Time at Current Residence
Years
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
30+
Months
0
1
2
3
4
5
6
7
8
9
10
11
Please choose housing situation
Home Owner
Renter
Live with Parents
Other
Drivers License Number
Drivers License State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Current Employer Name
(If Self Employed, please list your company name.)
Time with Employer
Years
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
30+
Months
0
1
2
3
4
5
6
7
8
9
10
11
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
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip Code
2.
Name of Creditor
Account Number
Transfer Amount
$
.00
Payment Address
Address Line 2
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip Code
3.
Name of Creditor
Account Number
Transfer Amount
$
.00
Payment Address
Address Line 2
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip Code
Add Authorized Users (optional)
1.
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
First Name
MI
Last Name
Suffix
Jr
Sr
II
III
Name Displayed on Card
Relationship
Spouse
Daughter
Son
Relative
Other
Social Security Number
Birth Date
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
(yyyy)
Cell Phone Number
Number of cards requested
0
1
2
2.
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
First Name
MI
Last Name
Suffix
Jr
Sr
II
III
Name Displayed on Card
Relationship
Spouse
Daughter
Son
Relative
Other
Social Security Number
Birth Date
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
(yyyy)
Cell Phone Number
Number of cards requested
0
1
2
3.
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
First Name
MI
Last Name
Suffix
Jr
Sr
II
III
Name Displayed on Card
Relationship
Spouse
Daughter
Son
Relative
Other
Social Security Number
Birth Date
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
(yyyy)
Cell Phone Number
Number of cards requested
0
1
2