Pelican State Credit Union Credit Card Application Please print this form, fill it out and fax to 225-408-6200 Close this Page

General Information
Will you be applying for Individual or Joint Credit: Joint Individual
If applying for joint credit, please sign below to verify that you intend to apply for joint credit
Applicant:	Co-Applicant:
Marital Status: Complete marital status if this application is for:  a. Joint or secured credit, or  b. You reside in or rely on property located in a Community Property State. (AZ, CA, ID, LA, NM, NV, TX, WA, WI)   Unmarried   Married   Separated   This loan is not for joint or secured credit and I do not live in the states listed above.
Type of Card Requested:
Number of Cards Requested:	Limit Requested:

Primary Applicant:
Last Name:	Member Number:
First Name:	Middle Name:
Social Security Number (TIN):	Date of Birth:
Number of Dependents:	Ages of Dependents:
Home Phone Number:	Work Phone Number:
Other Phone Number:	Email Address:
Drivers License #:	Drivers License State:
Mother's Maiden Name:
Home Address
Address 1:
Address 2:
City:	State, Zip:
Time at Current Residence:	Residence Type: Rent Own Other:
Monthly Payment:
Previous Address
Address 1:
Address 2:
City:	State, Zip:
Time at Previous Residence:	Residence Type: Rent Own Other:
Present Employer
Name:	Phone Number:
Employment Status: Full Time Part Time Temp Retired Other (please specify):
Job Title:	Job Start Date:
Gross Salary:	per Year Month Hour
Alimony, child support, or separate maintenance income need not be revealed  if you do not wish to have it considered as a  basis for repaying this obligation.
Other Income:	per Year Month Hour
Other Income Source:
Previous Employer
Name:	Phone Number:
Employment Status: Full Time Part Time Temp Retired Other (please specify):
Job Title:	Job Start Date:
Job End Date:
Gross Salary:	per Year Month Hour

Co-Applicant:
Last Name:	Member Number:
First Name:	Middle Name:
Social Security Number:	Date of Birth:
Number of Dependents:	Ages of Dependents:
Home Phone Number:	Work Phone Number:
Other Phone Number:	Email Address:
Drivers License #:	Drivers License State:
Home Address
Address 1:
Address 2:
City:	State, Zip:
Time at Current Residence:	Residence Type: Rent Own Other:
Monthly Payment:
Previous Address
Address 1:
Address 2:
City:	State, Zip:
Time at Previous Residence:	Residence Type: Rent Own Other:
Present Employer
Name:	Phone Number:
Employment Status: Full Time Part Time Temp Retired Other (please specify):
Job Title:	Job Start Date:
Gross Salary:	per Year Month Hour
Alimony, child support, or separate maintenance income need not be revealed  if you do not wish to have it considered as a  basis for repaying this obligation.
Other Income:	per Year Month Hour
Other Income Source:
Previous Employer
Name:	Phone Number:
Employment Status: Full Time Part Time Temp Retired Other (please specify):
Job Title:	Job Start Date:
Job End Date:
Gross Salary:	per Year Month Hour

Additional Information

How would you prefer to be contacted?   Home Phone   Work Phone   Other Phone   Email Address   Other:

Special Instructions/Comments:

Signatures
Income verification is required; other information may be required. I certify that statements on this application are true and complete. I authorize any person, association, firm or corporation to furnish, on request of this Financial Institution, information concerning me or my affairs. Section 1014, Title 18 of the U.S. Code makes it a federal crime to knowingly make a false statement on this application.
Primary Applicant Signature:	Date:
Co-Applicant Signature:	Date: