Secure Form – VISA Application



This form can be custom made for your credit union or used as-is. It can be embedded in your credit union website, mobile app or even It’s Me 247 Online Banking (desktop). Member submissions to these forms are secured in the CU Publisher Request Center. An email will be sent that a member has submitted this request. It is then your credit union’s staff’s responsibility to log in to Request Center to vet and fulfill the request per your procedures.



  • (Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as basis for repaying this obligation.)
  • Payment Protection

    Success CU Payment Protection is available for a nominal fee. This coverage may cancel your payments due to Loss of Life or Disability from injury and/or sickness. If you are interested in Debt Protection, please indicate by selecting below:
    This statement is submitted to obtain credit and I/we certify that all information herein is true and complete. I/We also authorize the Credit Union to verify or obtain further information the Credit Union may deem necessary concerning my/our credit standing. If this application is approved and a Visa card(s) issued, the undersigned applicant(s) by signing, using, or permitting another to use the Visa card(s) agree(s) that the applicant(s) will be bound by the terms and conditions accompanying the Visa card(s) and all amendments. By clicking “Submit” below, you agree that this Credit Union has a security interest pledge, in all future shares, share drafts, and deposits with us. To the extent in which you have a right to withdraw those sums for your personal use, the Credit Union may transfer from any deposit account to your Visa account if you are delinquent or otherwise in default. In addition, collateral securing your other loans with the Credit Union account(s) will also secure credit extended under this agreement. If you withdraw all your shares, you are no longer a member of the Credit Union, and you may not receive any more advances under this agreement.