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