Student Secured VISA Application - Go Energy Credit Union

Please read over the Consumer Credit Card Agreement.

What is your desired credit line?

Last Name

First

Middle

Date of Birth

SSN

Driver's License No

State Issued

Member Number

Email

Where did you attend school?

Present Address

City

State

Zip Code

How Long There

Telephone No

Cell Phone No

IF less than 1 year at current address

Previous Address

Previous City

Previous State

Previous Zip Code

How Long There — Previous

No. of Dependents

Marital Status

Married
Single
Divorced

Employers Name

Employers Address

Employers Phone No

Position/Occupation

Pay Frequency

Weekly
Bi-Weekly
Semi-Mo.
Monthly

Years Employed

Gross Income

Previous Employer

Other Income

Other Income Source

Reference

Reference Last Name

Reference First Name

Reference Middle Initial

Reference Address

Reference City

Reference State

Reference Zip

Reference Telephone No

Relationship

Other Information About You

Applicant

Yes
No

If you answer "Yes" to any question other than #1, explain below.

Are You A U.S. Citizen or Permanent Alien?

Yes
No

DO YOU CURRENTLY HAVE ANY OUTSTANDING JUDGEMENTS OR HAVE YOU EVER FILED FOR BANKRUPTCY, HAD A DEBT ADJUSTMENT PLAN CONFIRMED UNDER CHAPTER 13, HAD PROPERTY FORE CLOSED UPON OR REPOSSESSED IN THE LAST 7 YEARS, OR BEEN A PARTY IN A LAWSUIT?

Yes
No

If Yes, please explain

Savings Secured Credit Card Pledge

Savings Pledge

By check this box, I pledge the balance on deposit in my savings account type 05 at Go Energy Financial as security for my VISA Credit Card account. I understand this deposit in savings account type 05 will not be available to me for use until the VISA Credit Card is satisfactorily closed. I authorized Go Energy Financial to apply this account balance to my credit card balance if I am in default.

Signature(s)

Signature

By submitting this application to the Credit Union, I/we promise that everything is correct to the best of my/our. I/we authorize the Credit Union to obtain credit reports in connection with this application for credit and for any update, renewal or extension of the credit received. I/we understand that the Credit Union will rely on both the representations I/we make in this application and the contents of any credit report it obtains when deciding whether to grant the credit requested. I/we agree to immediately notify you of changes to any of the information provided in this application. I/we agree that my/our account will be subject to the terms and conditions of all applicable agreements and disclosures that will accompany my cards when issued; and that a photocopy or facsimile of this application shall be as binding as the original.

By submitting this application electronically, I/we agree to the same terms that apply to a signed application. If there is a co-applicant on this loan, that co-applicant has authorized the submission of this application. This electronic submission qualifies as my/our signature.

I understand that I must have a Go Energy Financial savings account that will be used as collateral for the VISA secured credit card. I understand I will not be able to make any withdrawals from the Go Energy Financial savings account while it secures this credit card. The balance required for the Go Energy Financial savings account will be 125% of the VISA credit limit.

Signature

Date

VISA Account Updater

VISA Updater OPT OUT

Whenever you receive a new, or renewed, VISA card, your old card's information (i.e., card number and expiration date) will automatically update to the new card's number and expiration date - for participating merchants with whom you maintain your card on file for recurring payments. YOU MAY OPT OUT: By checking the box, I wish to opt out of VISA Account Updater (VAU) for my Go Energy Financial Credit Card. I understand it will be my responsibility to notify merchants, who maintain my card on file information for recurring payments with any updated information regarding my Go Energy Financial Credit Card.