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CREDIT APPLICATION
VISA® & MASTERCARD® 

CHECK CARD OF CHOICE:

 VISA®

$15 Annual Fee
25-Day Grace Period

 MasterCard®
No Annual Fee
No Grace Period

ACCOUNT TYPE
(Check Only One)

 INDIVIDUAL ACCOUNT
 JOINT ACCOUNT

$15.00 ANNUAL FEE WITH 25-DAY GRACE PERIOD

ANNUAL 
PERCENTAGE RATE 
FOR PURCHASE & 
CASH ADVANCES

15.60%

VARIABLE RATE
INFORMATION

ANNUAL
MEMBERSHIP 
FEE

GRACE 
PERIOD

METHOD OF COMPUTING
THE BALANCE
FOR PURCHASES

MINIMUM
FINANCE
CHARGE

TRANSACTION
FEE FOR
PURCHASES

CASH 
ADVANCE 
FEE

LOST/
STOLEN 
CARD FEE

LATE
PAYMENT
FEE

OVER
CREDIT
LIMIT FEE

The annual percentage rate may 
vary semi-annually beginning april 
1, 2010. The variable rate will range 
between 0% and 16% above the 
prime rate published in the wall 
street journal on the 1st day of the 
prior month. the variable rate today, 
at maximum, would be 19.25%.

$15

25
DAYS*

AVERAGE DAILY
BALANCE
INCLUDING NEW
PURCHASES*

$0

$0

$0

$20

$20

$0

NO ANNUAL FEE; NO GRACE PERIOD

ANNUAL 
PERCENTAGE RATE 
FOR PURCHASE & 
CASH ADVANCES

15.60%

VARIABLE RATE
INFORMATION

ANNUAL
MEMBERSHIP 
FEE

GRACE 
PERIOD

METHOD OF COMPUTING
THE BALANCE
FOR PURCHASES

MINIMUM
FINANCE
CHARGE

TRANSACTION
FEE FOR
PURCHASES

CASH 
ADVANCE 
FEE

LOST/
STOLEN 
CARD FEE

LATE
PAYMENT
FEE

OVER
CREDIT
LIMIT FEE

The annual percentage rate may 
vary semi-annually beginning april 
1, 2010. The variable rate will range 
between 0% and 16% above the 
prime rate published in the wall 
street journal on the 1st day of the 
prior month. the variable rate today, 
at maximum, would be 19.25%.

$0

None

AVERAGE DAILY
BALANCE
INCLUDING NEW
PURCHASES*

$0

$0

$0

$20

$20

$0

The information about the costs of the cards described in this application are accurate as of the REV date in the lower-left hand corner. The terms are subject to change after that date. 
For current information on the costs of these cards, contact: Pinnacle Bank, PO Box 461209, Papillion, NE 68046, (402) 339-3244 or 1-800-369-7283 (RATE)

APPLICANT Note: All Sections Should be Filled Out Completely. If Not, Processing Of Your Application May Be Delayed.

Last Name 

                                                                            First                                                                                 Middle   

                             Social Security #

Date of Birth 

                     No. of Dependents 

Home Telephone 

 Own  

 Rent  

 Other 

                             Mo. Payments $

Street Address 

Employment 

Address 

Name and Address of Previous Employer 

Source of Additional Income* 

                                 City                                                               State                               Zip Code                                 How Long (yrs)

                         Self Employed?   

 Yes   

 No                     Telephone Number   

    How Long (yrs)

Position/Occupation 

                             Monthly Gross Income

    How Long (yrs)

    Amount per Month $

Nearest Relative (Not Living With You) 

Telephone Number 

                             Relationship

Relative’s Address                                                                                                 City 

                               State 

    Zip Code

* You need not furnish alimony, child support or maintenance information, if you do not want us to consider it in evaluating your application.

CO-APPLICANT Note: Provide the Following Information Only if Co-Applicant is a Joint Applicant or Will Be an Account User.

Last Name 

                                                                            First                                                                                 Middle   

                             Social Security #

Date of Birth 

                     No. of Dependents 

Home Telephone 

 Own  

 Rent  

 Other 

                             Mo. Payments $

Street Address 

Employment 

Address 

Name and Address of Previous Employer 

Source of Additional Income* 

                                 City                                                               State                               Zip Code                                 How Long (yrs)

                         Self Employed?   

 Yes   

 No                     Telephone Number   

    How Long (yrs)

Position/Occupation 

                             Monthly Gross Income

    How Long (yrs)

    Amount per Month $

* You need not furnish alimony, child support or maintenance information, if you do not want us to consider it in evaluating your application.

NAME OF INSTITUTION 

DATE OPEN 

                                        AVERAGE BALANCE

FINANCIAL REFERENCE

 Checking Account

 Savings Account

 CD

 Other

CREDIT CARDS

ISSUER 

CREDIT LIMIT 

BALANCE 

                                        PAYMENT AMOUNT

TYPE OF DEBT 

CREDITOR 

ORIGINAL BALANCE 

PRESENT BALANCE 

MONTHLY PAYMENT

OTHER

1. Automobile

2. Mortgage

3. 

4.

Are you a co-maker, endorser or
guarantor on any loan or contract?

                              Yes  

       No  

Are there any unsatisfied 
judgments against you?                               Yes  
Have you been declared
bankrupt in the last 10 years?

                              Yes  

       No  

       No  

If “Yes,”
for whom?

Amount $
If “Yes,”
where? 

ENROLLMENT BOX

$

$

$

$

$

$

To whom?

If “Yes,”
to whom owed?

Year

Sign here to protect your account balance with Life, Disability, Unemployment and Family Leave Insurance by enrolling in the Optional Group Credit Card Insurance Program. I 
acknowledge that I have read the Disclosure Statement on the reverse side of this application. Enrollment is voluntary and you are free to cancel at any time.

  _______________________                              ____________________________________
         Initial Here to Enroll                                                           Print Name of Primary Applicant

                __________________                                         _______________________    
                                Birth Date 

Initial Here to Decline

Form C485 8/01

SIGNATURE(S)

PLEASE  READ  THE  FOLLOWING  CAREFULLY  BEFORE  SIGNING:  This  statement  is  submitted  to  obtain  credit  and  I/we  certify  that  all  information  herein  is  true  and  complete.  I/We 
agree that inquiries may be made to verify information and that credit references or verification may be given based on inquiries from other parties. This offer is subject to the credit policies of 
this institution. I/We agree to be bound by the terms and conditions of the bank card agreement, a copy of which will be mailed to the applicant if this application is granted, receipt of such 
agreement and acceptance of such terms to be conclusively presumed by the applicant’s use. If this is a joint application, the undersigned shall be jointly and severally liable for any and all 
credit extended from time to time.

X  __________________________________________________________________________    

X  __________________________________________________________________________    

Title 

Date

         Co-Applicant Signature 

Title 

Date

         Applicant Signature 

REV. 11.09

Fold and secure with tape for mailing.

Member FDIC