First Citizens Bank Limited

VISA PURPLE CARD

APPLICATION FORM
BRANCH DATE
NAME Mr Mrs Miss Ms DATE OF BIRTH MARITAL STATUS
(in full)
Day No. of Dependents
First Middle Surname Month Spouse’s Name
Year Spouse’s Employers
ID No./PP No./DP No. (identification required and copied)
MOTHER’S MAIDEN NAME
RESIDENTIAL STATUS Owner Tenant With Parents Other
HOME ADDRESS YEARS AT PRESENT ADDRESS
(Proof required)
EMAIL TEL. NO.
PREVIOUS ADDRESS (If less than 3 years)
NAME & ADDRESS OF EMPLOYER TEL. NO.

NAME & ADDRESS OF LANDLORD

OR MORTGAGE HOLDER
REFERENCE (Relative or friend not living
at your address) NAME, ADDRESS AND TEL. NO.
RELATIONSHIP
OCCUPATION (Confirmation to be provided) TIME IN JOB (Years)
IF LESS THAN 3 YEARS,
NAME, ADDRESS & TEL. NO. OF PREVIOUS EMPLOYER

SALARY (Recent payslip to be produced) Customer to initial his/her chosen options below.
IS YOUR SALARY ALREADY ASSIGNED? YES/NO (If yes, to whom) MONTHLY PAYMENT: From Acct. No. Minimum Full
CAN IT BE ASSIGNED TO THIS OFFICE? YES/NO MONTHLY CONTRIBUTION: $25 $50 $75 $100
INCOME $ EXPENDITURE $ BANKING INFORMATION
Gross Salary ..................... Insurance Premiums .................... Tick A - Applicant B - Co-applicant
Partner’s Income (if appropriate) ..................... Mortgage/Rent ....................
Name of Type of
A B Branch Balance
Other Income (Details/evidence
..................... Income Tax, N.I.S. .................... Bank Account No.
to be provided)

..................... Pension & Health ....................

..................... Credit Union/Loan Payments ....................
..................... Food, housekeeping etc. ....................
..................... Travel ....................
..................... Vehicle Maintenance ....................
..................... (gas, oil, tyres, insurance)
..................... Utilities, gas, electricity, telephone ....................
..................... Other Payments ....................
LENGTH OF BANKING RELATIONSHIP WITH FIRST CITIZENS YRS
SUBTOTAL $__________ OTHER CREDIT CARDS HELD BY YOU

________ SURPLUS $__________ Republic Scotia

TOTAL $ _________ TOTAL $__________ RBC Other
ASSETS $ LIABILITIES $
Deposits ................... Mortgage ...................
Credit Union Shares ................... Bank Loan/Overdrafts ...................
Life Insurance C.S.V. ................... Insurance Policy Loans ...................
Real Estate ................... Hire Purchase ...................
Vehicles ................... Credit Union Loans ...................
Other ................... Other ...................
TOTAL $ ________ TOTAL $________
 VISA CARD APPLICATION FORM (Continued)

I/We confirm that I/we have signed the appropriate copy of the Credit Card Agreement, acknowledging the terms for operating the Account.
I/WE AGREE TO THE FOLLOWING:-

1. All information given herein is true, accurate, and complete to the best of my/our knowledge, and was provided for the purpose of obtaining a Credit Card. I/
We confirm that I am/we are not being sued, that there is no unsatisfied judgement outstanding against me/us, and that I am/we are not indebted to any other
lending institution except as shown in this application.

2. Whilst I/we have the Account I/we will not seek a loan elsewhere without first informing the Bank.

3. This form will remain the property of the bank whether or not the application is approved.

4. “I/We, authorize and consent to the Bank obtaining further information on my/our credit and employment history from any financial institution, credit bureau
or any other person/corporation with whom I/we may have had dealings with from time to time and any such source is hereby authorized to provide the Bank
with the requested information. You are authorized to disclose to any Credit Bureau and other credit grantors any information about my/our credit history. I/
We jointly and severally agree to indemnify you against any loss, claims, damages, liabilities, actions and proceedings; legal and or other expense which may
be directly or reasonably incurred as a consequence of such disclosure on your part.”

5. The Bank has my/our authority to debit my/our Account for the minimum monthly payments.

6. The Bank has my/our authority to debit my/our VISA PURPLE credit card account, once approved, for the sum indicated on the reverse side of this page.

SIGNED THIS DAY OF 20

BANK WITNESS APPLICANT’S SIGNATURE (1)

Do not write below this line (For Bank use only)

APPLICATION REFERENCE NO.

CHECKS MADE INTERNALLY

OUTSIDE CREDIT CHECK REQUIRED (Comments attached)

SECURITY REQUIRED LENDING VALUE SATISFIED

Promisory Note ..................................... ..................................... .....................................

Mortgage ..................................... ..................................... .....................................

Life Insurance ..................................... ..................................... .....................................

Fire Insurance ..................................... ..................................... .....................................

Vehicle Insurance ..................................... ..................................... .....................................

Guarantee ..................................... ..................................... .....................................

Mortgage Bill of Sale ..................................... ..................................... .....................................

Fixed Deposits ..................................... ..................................... .....................................

Other ..................................... ..................................... .....................................

I confirm that I have personally I confirm that I have personally checked the
checked the form, the identification/ Credit score, and confirm that it is within the
confirmations required, and have Credit current guidelines. I have satisfied myself that
Scored it. The Account is approved all the conditions required have been met, and
within the current guidelines. I have therefore approved the issue of the Card.

AMOUNT APPROVED TT$

CREDIT OFFICER CREDIT/APPROVING OFFICER

DATE