Credit Card Application

VARIABLE RATE

(See back panel for rate information)

Platinum Elite Visa®
Platinum Elite Rewards Visa® 
Platinum Elite Cash Back Visa® 
Secured Classic Visa® 

ACCOUNT
TYPE

INDIVIDUAL

JOINT

CREDIT UNION
ACCOUNT NUMBER

APPLICANT
If you are applying for credit in your own name, complete Applicant portion only.

CO-APPLICANT
Co-Applicant / Co-signer / Guarantor, must complete Co-Applicant side.

NAME - LAST 

FIRST 

M.I.

NAME - LAST 

FIRST 

M.I.

HOME ADDRESS - STREET

HOW LONG

HOME ADDRESS - STREET

HOW LONG

CITY 

STATE 

ZIP CODE

CITY 

STATE 

ZIP CODE

HOME PHONE

BUSINESS PHONE

HOME PHONE

BUSINESS PHONE

DATE OF BIRTH

SOCIAL SECURITY NO.

DATE OF BIRTH

SOCIAL SECURITY NO.

EMPLOYER

DATE HIRED

EMPLOYER

DATE HIRED

POSITION OR JOB TITLE

GROSS MONTHLY PAY
$

POSITION OR JOB TITLE

GROSS MONTHLY PAY
$

PREVIOUS EMPLOYER IF LESS THAN 2 YEARS

HOW LONG

PREVIOUS EMPLOYER IF LESS THAN 2 YEARS

HOW LONG

HOME

OWN 

RENT

MONTHLY PAYMENT
$

NOTE 

Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this loan.

SOURCE OR KIND

OTHER
INCOME

PAYOR

PLEASE ISSUE VISA®
CARD(S) EMBOSSED WITH EACH
NAME PRINTED HERE

MONTHLY AMOUNT
$
IS INCOME LIKELY
TO BE REDUCED
IN 2 YEARS?
1. PLEASE PRINT

YES 

SOURCE OR KIND

OTHER
INCOME

PAYOR

NO

2. PLEASE PRINT

MONTHLY AMOUNT
$
IS INCOME LIKELY
TO BE REDUCED
IN 2 YEARS?

YES 

NO

NUMBER OF
CARDS DESIRED

TRANSFER
AUTHORIZATION —
I WANT TO TRANSFER
THE CREDIT CARD
ACCOUNT(S) SHOWN
TO MY NEW LAKE TRUST 
CREDIT UNION 
ACCOUNT. THESE 
TRANSFERS WILL 
BE TREATED AS A 
CASH ADVANCE. 

1 

2 

3

LIMIT REQUESTED

$

NOTE

IF YOU ARE REQUESTING A LINE OF
CREDIT INCREASE, PROVIDE YOUR
VISA ACCOUNT NUMBER

1. CARD ISSUER

ADDRESS — STREET

2. CARD ISSUER

ACCOUNT NO.

BALANCE TO TRANSFER

CITY 

STATE 

ZIP CODE

TELEPHONE NO.

ACCOUNT NO.

BALANCE TO TRANSFER

ADDRESS — STREET

CITY 

STATE 

ZIP CODE

TELEPHONE NO.

OPTIONAL LOAN PROTECTION INFORMATION (NOT REQUIRED FOR APPROVAL)

CHECK OPTION DESIRED. A SEPARATE DOCUMENT WHICH DISCLOSES THE TERMS AND CONDITIONS MUST BE SIGNED FOR COVERAGE TO BECOME EFFECTIVE.
Would you like Lake Trust Loan Protection?
Would you like Lake Trust Loan Protection Plus?
No Protection

___________ Initial
___________ Initial
___________ Initial

IF YOU CHECKED YES ABOVE, YOU WILL RECEIVE ADDITIONAL INFORMATION AND FORM(S) TO SIGN THAT WILL INITIATE COVERAGE.

This statement is submitted to obtain credit and I (we) certify  that all information herein is true and complete. I (We) also authorized Lake Trust 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® 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® and all amendments. By signing an application you are also granting a security interest in any present and future share or deposit 
accounts in the credit union in which you have an interest excepting those accounts that would have an adverse tax consequence. You understand that by signing you are giving the credit union a consensual lien on 
your shares and other accounts. You understand granting a security interest is a condition for the credit card account and you give Lake Trust Credit Union a security interest in all funds now or hereafter in all of my 
deposit accounts (except IRA), and if I default under the terms of this agreement I authorize you to apply such funds to the payment of my credit card indebtedness.

FOR SECURED VISA ONLY

I/We agree to give the Lake Trust Credit Union a security interest in the following share deposit account: __________________________________________________________________________ I/We have in the Lake Trust 
Credit Union as a condition of obtaining credit under the Secured Visa® credit card. I/We understand that the Visa® will be secured by shares equal to 110% of the credit line approved for the duration of the loan, 
regardless of the outstanding Visa® balance.
I/We agree that the Lake Trust Credit Union may withdraw money from the share deposit account to pay any amount that is due twenty-five (25) days after my/our monthly statement closing date.

APPLICANT SIGNATURE

DATE

CO-APPLICANT/CO-SIGNER/GUARANTOR SIGNATURE

DATE

X

X

CREDIT UNION USE ONLY

APPROVED

DENIED

COUNTER
OFFER

(SPECIFY)

VISA
LINE OF
CREDIT LIMIT

LOAN OFFICER SIGNATURE 

DATE

REASONS FOR DENIAL/COUNTER OFFER

SEE BACK PANEL FOR CREDIT TERMS

FOLD THIS FLAP FIRST

FOLD UP AND SEAL WITH TAPE

4605 S Old US Highway 23
Brighton, MI 48114
888.267.7200
laketrust.org

Interest Rates and Interest Charges 
Annual Percentage Rate (APR) for 
Purchases 

Interest Rates and Interest Charges

Annual Percentage Rate (APR) for 
Purchases

APR for Cash Advances 

VISA PLATINUM ELITE AND 
PLATINUM ELITE VISA
VISA PLATINUM ELITE REWARDS
PLATINUM ELITE REWARDS VISA
APPLICATION AND SOLICITATION DISCLOSURE
PLATINUM ELITE CASH BACK VISA
SECURED CLASSIC VISA
APPLICATION AND SOLICITATION DISCLOSURE

Visa Platinum Elite 

8.90%, 9.90%, 10.90%, 15.90% or 18.90%
when you open your account, based on your creditworthiness. This 
Platinum Elite Visa
APR will vary with the market based on the Prime Rate. 
8.40% ,  9.40% ,   11.40% ,   13.40%,   or    
Visa Platinum Elite Rewards 
15.40%  when you open your account, based on your 
10.90%, 11.90%, 12.90%, 17.90% or 20.90%
creditworthiness. This APR will vary with the market based on the  
Prime Rate.
when you open your account, based on your creditworthiness. This 
APR will vary with the market based on the Prime Rate. 

Platinum Elite Rewards Visa/Platinum Elite Cash Back Visa
Visa Platinum Elite 
10.40% ,  11.40% ,   13.40% ,   15.40% ,   or  
11.90%, 12.90%, 13.90%, 18.90% or 21.90%
17.40%  when you open your account, based on your  
when you open your account, based on your creditworthiness. This 
APR will vary with the market based on the Prime Rate. 
creditworthiness. This APR will vary with the market based on the  
Prime Rate.

Visa Platinum Elite Rewards 

APR for Balance Transfers 

APR for Balance Transfers

13.90%, 14.90%, 15.90%, 20.90% or 23.90%
Secured Classic Visa
when you open your account, based on your creditworthiness. This 
10.00%
APR will vary with the market based on the Prime Rate. 
This APR will vary with the market based on the Prime Rate.

Visa Platinum Elite 

Platinum Elite Visa
11.90%, 12.90%, 13.90%, 18.90% or 21.90%
11.40% ,  12.40% ,   14.40% ,   16.40% ,   or  18.40%  when you open 
when you open your account, based on your creditworthiness. This 
your account, based on your creditworthiness. This APR will vary with the 
APR will vary with the market based on the Prime Rate. 
market based on the Prime Rate.

Visa Platinum Elite Rewards 

Platinum Elite Rewards Visa/Platinum Elite Cash Back Visa
13.90%, 14.90%, 15.90%, 20.90% or 23.90%
13.40% ,  14.40% ,   16.40% ,   18.40% ,   or  20.40%  when you open 
when you open your account, based on your creditworthiness. This 
your account, based on your creditworthiness. This APR will vary with the 
APR will vary with the market based on the Prime Rate. 
market based on the Prime Rate.

How to Avoid Paying Interest on Purchases  Your due date is at least 25 days after the close of each billing cycle.  

For Credit Card Tips from the Federal 
Reserve Board 

APR for Cash Advances

Fees 

Transaction Fees 

•  Foreign Transaction Fee 

Penalty Fees 

•  Late Payment Fee 
•  Returned Payment Fee 

We do not charge you interest on purchases if you pay your entire 
Secured Classic Visa
balance by the due date each month.   
13.00%
To learn more about factors to consider when applying for or using a 
This APR will vary with the market based on the Prime Rate.
credit card, visit the Web site of the Federal Reserve Board at 
http://www.federalreserve.gov/creditcard. 

Platinum Elite Visa
11.40% ,  12.40% ,   14.40% ,   16.40% ,   or  18.40%  when you open your 
account, based on your creditworthiness. This APR will vary with the market 
based on the Prime Rate.

           of each transaction in U.S. dollars 
1.00%

Platinum Elite Rewards Visa/Platinum Elite Cash Back Visa
$35.00
13.40% ,  14.40% ,   16.40% ,   18.40% ,   or  20.40%  when you open your 
account, based on your  
           per returned payment 
$28.00
creditworthiness. This APR will vary with the market based on the Prime Rate.

How We Will Calculate Your Balance. We use a method called “average daily balance (including new purchases).”  

Secured Classic Visa
13.00%
Effective  Date.  The  information  about  the  costs  of  the  card  described  in  this  application  is  accurate  as   
This APR will vary with the market based on the Prime Rate.
This information may have changed after that date. To find out what may have changed, contact the Credit Union. 
None

Penalty APR and When it Applies

01/01/2010.

OTHER DISCLOSURES 

©CUNA Mutual Group 2009, 10, 12, All Rights Reserved

Other Fees 

•  Statement Copy Fee 
•  Rush Fee 

•  Stop Payment Fee 

•  Research Fee 

•  Sales Draft Copy Fee 

•  Card Replacement Fee   

©CUNA MUTUAL GROUP, 2009, ALL RIGHTS RESERVED 

SEE NEXT PAGE for more important information about your account.

02101376-MXC40-C-1-051216 (MCX403) CCM003)-e

           per statement 
$2.00
           per card 
$20.00
           per request  

$28.00

           per sales draft 

$5.00

             per card 

$25.00

           per hour, minimum of one (1) hour 

$20.00

DMIFW0 (MXC400)-e 

 
 
           
           
           
           
           
           
 
 
            
 
 
 
How to Avoid Paying Interest  
on Purchases

Your due date is at least 25 days after the close of each billing cycle. We will 
not charge you any interest on purchases if you pay your entire balance by 
the due date each month.

For Credit Card Tips from the Consumer 
Financial Protection Bureau

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

Fees
Annual Fee
- Annual Fee 

Transaction Fees
- Foreign Transaction Fee 

Penalty Fees
- Late Payment Fee 
- Returned Payment Fee 

None

1.00%       of each transaction in U.S. dollars

Up to  $35.00
Up to  $25.00

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 May 15, 2016.
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 
Statement Copy Fee 
Rush Fee 
Card Replacement Fee 
Research Fee 
Sales Draft Copy Fee 
Stop Payment Fee 

 $25.00   or the amount of the required minimum payment, whichever is less, 
if your payment is not received by the next statement closing day.  The next 
statement closing day varies by month from 2-6 days after your payment due 
date.  In the event you fail to make a payment on time in any of the six billing 
cycles following the intital violation, you will be charged $35.00  or the amount 
of the required minimum payment, whichever is less.
$25.00   or the amount of the required minimum payment, whichever is less.
$2.00
$20.00
$25.00
$20.00  per hour, minimum of one (1) hour
$5.00 
$28.00  per request

per sales draft

310 (05/16)

02101376-MXC40-C-1-051216 (MCX403) CCM003)-e