Credit Card Application
A  table  that  includes  required  credit  card  disclosures  is  on  a  separate 
document  provided  with  this  Application.  To  obtain  any  change  in  the 
required information since it was printed, write to us at the address stated on 
this Application. 

Check below to indicate the type of credit for which you are applying.  Married Applicants may apply for a separate account.

Individual Credit: You must complete the Applicant section about yourself and the Other section about your spouse if:

1. you live in or the property pledged as collateral is located in a community property state (AK, AZ, CA, ID, LA, NM, NV, TX, WA, WI);
2. your spouse will use the account, or
3. you are relying on your spouse's income as a basis for repayment. If you are relying on income from alimony, child support, or separate maintenance,

complete the Other section to the extent possible about the person on whose payments you are relying.
Joint Credit: Each Applicant must individually complete appropriate section below. If Co-Borrower is spouse of the applicant, mark the Co-Applicant
box.

Guarantor: Complete the Other section if you are a guarantor on an account/loan.

Credit Limit Requested $

APPLICANT

NAME (Last - First - Initial)

OTHER

NAME (Last - First - Initial)

CO-APPLICANT

SPOUSE

OTHER

ACCOUNT NUMBER

SOCIAL SECURITY NUMBER

ACCOUNT NUMBER

SOCIAL SECURITY NUMBER

DRIVER'S LICENSE NUMBER/STATE

EMAIL ADDRESS

DRIVER'S LICENSE NUMBER/STATE

EMAIL ADDRESS

BIRTH DATE

HOME PHONE

CELL PHONE

BUSINESS PHONE/EXT.

BIRTH DATE

HOME PHONE

CELL PHONE

BUSINESS PHONE/EXT.

PRESENT ADDRESS (Street - City - State - Zip)

OWN

RENT

LENGTH AT RESIDENCE

PRESENT ADDRESS (Street - City - State - Zip)

OWN

RENT

LENGTH AT RESIDENCE

MORTGAGE/RENT OWED TO:

MORTGAGE/RENT OWED TO:

MORTGAGE BALANCE
$
COMPLETE FOR JOINT CREDIT, SECURED CREDIT OR IF YOU LIVE IN A COMMUNITY PROPERTY
STATE:

MONTHLY PAYMENT
$

INTEREST RATE
%

UNMARRIED (Single - Divorced - Widowed)

SEPARATED

MARRIED

MORTGAGE BALANCE
$
COMPLETE FOR JOINT CREDIT, SECURED CREDIT OR IF YOU LIVE IN A COMMUNITY PROPERTY
STATE:

MONTHLY PAYMENT
$

INTEREST RATE
%

UNMARRIED (Single - Divorced - Widowed)

SEPARATED

MARRIED

EMPLOYMENT/INCOME

START DATE

EMPLOYMENT/INCOME

START DATE

NAME AND 
ADDRESS OF 
EMPLOYER

NAME AND
ADDRESS OF 
EMPLOYER

NOTICE: ALIMONY, CHILD SUPPORT, OR SEPARATE MAINTENANCE INCOME NEED NOT BE

NOTICE: ALIMONY, CHILD SUPPORT, OR SEPARATE MAINTENANCE INCOME NEED NOT BE

REVEALED IF YOU DO NOT CHOOSE TO HAVE IT CONSIDERED.

REVEALED IF YOU DO NOT CHOOSE TO HAVE IT CONSIDERED.

EMPLOYMENT INCOME

$_____________ Per ______________

OTHER INCOME
$_____________ Per ______________

EMPLOYMENT INCOME
$_____________ Per _____________

OTHER INCOME
$_____________ Per _______________

NET

GROSS

SOURCE

NET

GROSS

SOURCE

STATE LAW NOTICES

OHIO RESIDENTS ONLY: The Ohio laws
against discrimination require that all creditors
make credit equally available to all creditworthy customers, and that credit
reporting agencies maintain separate credit histories on each individual
upon request. The Ohio Civil Rights Commission administers compliance
with this law.

unless the Credit Union is furnished a copy of the agreement, statement
or decree, or has actual knowledge of its terms, before the credit is
granted or the account is opened. (2) Please sign if you are not applying
for this account or loan with your spouse. The credit being applied for, if
granted, will be incurred in the interest of the marriage or family of the
undersigned.

WISCONSIN RESIDENTS ONLY: (1) No provision of any marital property
agreement, unilateral statement under Section 766.59, or court decree
under Section 766.70 will adversely affect the rights of the Credit Union

X

SIGNATURE FOR WISCONSIN RESIDENTS ONLY

DATE

SIGNATURES

1. You promise that everything you have stated in this application is
correct to the best of your knowledge. If there are any important changes
you will notify us in writing immediately. You authorize the Credit Union to
obtain credit reports in connection with this application for credit and for
renewal, extension, or collection of the credit
any update,
received. You understand that the Credit Union will rely on the information
in this application and your credit report to make its decision. If you
request, the Credit Union will tell you the name and address of any credit
bureau from which it received a credit report on you. It is a crime to
willfully and deliberately provide incomplete or incorrect information in this
application.

increase,

of your

the use

card will

understand that

2. You
constitute
acknowledgment of receipt and agreement to the terms of the credit card
agreement and disclosures. You grant us a security interest
in all
individual and joint share and/or deposit accounts you have with us now
and in the future to secure your credit card account. When you are in
default, you authorize us to apply the balance in these accounts to any
amounts due. Shares and deposits in an Individual Retirement Account,
and any other account that would lose special tax treatment under state
or federal law if given as security, are not subject to the security interest
you have given in your shares and deposits.

X

APPLICANT'S SIGNATURE

(SEAL)

X

DATE

OTHER SIGNATURE

CREDIT UNION USE ONLY

(SEAL)

DATE

APPROVED

NO. OF CARDS

CREDIT LIMIT $

CREDIT CARD NUMBER

DECLINED

CREDIT COMMITTEE OR LOAN OFFICER SIGNATURE

CUNA Mutual Group 2009 All Rights Reserved

AXC002-e

 
 
 
 
 
APPLICATION AND SOLICITATION DISCLOSURE 

F1             

Interest Rates and Interest Charges 
Annual Percentage Rate (APR) for 
Purchases 

APR for Cash Advances 

Paying Interest 
For Credit Card Tips from the Consumer 
Financial Protection Bureau 

Fees 
Transaction Fees 
-  Foreign Transaction Fee 
Penalty Fees 
-  Late Payment Fee 
-  Returned Payment Fee 
-  Returned ACH Payment Fee 

Standard MasterCard 

F2          to F3          when you open your account, based 
on your creditworthiness. 

Gold MasterCard 

F4          to F5          when you open your account, based 
on your creditworthiness. 
Standard MasterCard 

F6          to F7          when you open your account, based on your 
creditworthiness. 

Gold MasterCard 

F8          to F9          when you open your account, based on your 
creditworthiness. 
We will begin charging interest on purchases on the transaction date.  
To learn more about factors to consider when applying for or 
using a credit card, visit the website of the Consumer Financial 
Protection Bureau at http://www.consumerfinance.gov/learnmore. 

F10        of each transaction in U.S. dollars 

Up to F11            
Up to F12           
Up to F13           

How We Will Calculate Your Balance. We use a method called “average daily balance (including new purchases).”  

Effective Date.  
The information about the costs of the card described in this application is accurate as of F14            
This information may have changed after that date. To find out what may have changed, contact the Credit Union. 

OTHER DISCLOSURES 

Late Payment Fee 

Returned Payment Fee 

Returned ACH Payment Fee 

Card Replacement Fee 
Rush Fee 
Stop Payment Fee 

F15        or the amount of the required minimum payment, whichever is 
less, if you are ten (10) or more days late in making a payment. 
F16        or the amount of the required minimum payment, whichever is 
less. 
F17        or the amount of the required minimum payment, whichever is 
less. 
F18           
F19        2 days $55 Overnight 
F20           

©CUNA Mutual Group 2009, 10, 12 All Rights Reserved 

D42NW1 (MXC402 CCM002) 

STANDARD MASTERCARD/GOLD MASTERCARD5.90%18.00%5.90%18.00%5.90%18.00%5.90%18.00%1.00%$25.00$25.00$25.00February 1, 2014.$25.00$25.00$25.00$5.00$27.50$12.00