Citizens Bank & Trust
Visa® Student Credit Card Application
See Page 3 for important fees, rates and disclosures.
IMPORTANT NOTE: PROVIDING A GUARANTOR IS OPTIONAL TO BE CONSIDERED FOR CREDIT. HOWEVER, DEPENDING ON YOUR INCOME AND CREDIT HISTORY,
WE MAY DETERMINE THAT A GUARANTOR IS REQUIRED. THE GUARANTOR MUST BE ACCEPTABLE TO US AND CAN BE, FOR EXAMPLE, A PARENT, GUARDIAN OR
GRANDPARENT.
MAIL COMPLETED APPLICATION TO: CARD SERVICES, P. O. BOX 419734, KANSAS CITY, MO 64141-6734
EMPLOYEE# (M5) BRANCH# (M6) AGENT# 4690 (M2=VS CL9999)
APPLICANT INFORMATION
Name (first, middle, last)
Mother’s Maiden Name (for security purposes only)
Physical Address (No P. O. Boxes)
City
State
Zip Code
Mailing Address (if different)
City
State
Zip Code
Home Phone
Date of Birth
Social Security Number
How Long Yr. Mos.
Rent
Own
Housing Payment $
Employer Information (including Position Held)
Gross Annual Salary
$
Years There
Business Phone
Bank Name
Savings
Checking
OTHER SOURCE(S) OF INCOME: Alimony, child support or separate maintenance need not be revealed if you do not wish to have it considered as a
basis for repaying this obligation.
Name and address of nearest relative not living with you
GUARANTOR INFORMATION (OPTIONAL)
Name (first, middle, last)
Date of Birth
Social Security Number
Physical Address (if different from applicant, no P. O. Boxes)
City State
Zip Code
Employer Information (including Position Held)
Years There
Business Phone
Home Phone
Years There
Relationship to Applicant
OTHER SOURCE(S) OF INCOME: Alimony, child support or separate maintenance need not be revealed if you do not wish to have it considered as a
basis for repaying this obligation.
Signature of Applicant