Meridian Mutual Federal Credit Union Credit Card Application Please print this form, fill it out and fax to 601-482-5748 Close this Page

General Information
Will there be a co-applicant on this application? Yes No
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
Other Income:	per Year Month Hour
Other Income Source:
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.
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
Other Income:	per Year Month Hour
Other Income Source:
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.
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.(Sec. 1014, Title 18, 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: