• Indicates a required field.

• Type of Account Requested	Individual Joint VISA Classic VISA Gold


Choice of Card Design	Scottsbluff National Monument Tetons (Note Gold Design is shadow print only)
Next Done

• Full Name
• Date of Birth
• Social Security Number
• Home Phone
• Present Street Address
• City
• State
• Zip Code
• How Long at Address	Years: Months:
• Own or Rent	Own Rent
Previous Address (if less than 5 years at present address)
No. of Dependents


• Present Occupation
• Present Employer Address
• Present Employer Phone Number
• How Long at Present Employer	Years: Months:


Name and Address of Nearest Relative
Relative Phone


• Email Address
• Confirm Email Address
Next Done

Assets	Amount	Liabilities List Name of Creditors and Account Numbers	Monthly Payments	Balance
• Cash (List Name of Institution):	• $		$	$
CD's, Bonds and Etc.:	$		$	$
Stocks:	$		$	$
Cash Value of Life Insurance:	$		$	$
Home:	$		$	$
Other Assets (Detail):	$	• Mortgage/ Rent Payments	• $	$
• TOTAL	• $	• TOTAL	• $	• $
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Annual Income	Applicant	Annual Income	Co-Applicant
• Salary*	• $	Salary*	$
Commissions or Bonus	$	Commissions or Bonus	$
Dividends and Interest	$	Dividends and Interest	$
Alimony, child support or maintenance (you need not show this unless you wish it considered)	$	Alimony, child support or maintenance (you need not show this unless you wish it considered)	$
Other Income - List Source	$	Other Income - List Source	$
• TOTAL	• $	TOTAL	$
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Take advantage of your low interest rate by transferring balances from your higher rate cards to your new Platte Valley Visa account. Simply fill out the information below and sign the authorization, and we will transfer the amount listed to your new Platte Valley Visa account. What's more, there's absolutely no fee for this service. We'll handle all the paperwork - you pocket the interest savings. (Please remember, the total amount transferred may not exceed your credit line.) Please continue to pay any monthly statements you receive from the issuers listed on this form until you receive a statement showing no further balance is due.


Bank/Card Issuer:
Payment Address:
Account Number:
Ammount to Transfer:
Next Done

By clicking the agree box I/We certify that I am of legal age in the state in which I reside. I/We certify that the information provided is true and complete and agree to be bound by all the terms and conditions of the Cardholder Agreement and the Federal Truth in Lending Disclosures for the account which will be sent when the card is issued. I hereby authorize the Bank, or any credit bureau or other investigative agency employed by it, to investigate any information listed hereon or obtained from me or any other person pertaining to my financial responsibility. I understand that this offer is subject to a minimum household income of $9,600 and the request is for a Visa Classic account and certification of a satisfactory credit history or a minimum household account of $35,000 and the request is for a Visa Gold account and verification of a satisfactory credit history. See "Summary of Credit Terms" for important rate and fee information.


• Agree

Other Account Services

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