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NorState Federal Credit Union Visa Credit Card Application
A table that includes the APRs and other required cost disclosures for credit card applications is on the reverse side of this application.
Check the appropriate box below to indicate the type of credit for which you are applying.

❑ Individual credit. Complete Applicant section. Complete other section as follows:

Information about the party making payments only if you are relying on alimony, spousal
support, child support, or maintenance as a basis for repayment.

❑ Joint credit. Provide information about both of you
by completing Applicant and Co-Applicant sections.

Credit limit requested: $

Number of cards desired? ❑ 1 ❑ 2

APPLICANT Name

Street

City, State, Zip

Date of Birth

Mother’s Maiden Name

Social Security Number                      Driver’s License Number and State

Home Phone

Number of Dependents         Ages    

Gross Annual Income $

Net Monthly Pay $

Other Income $ 

Are you self employed?   ❑ Yes   ❑ No

Current Employer

Type of Business 

Previous Employer

CO-APPLICANT Name

Street

City, State, Zip

Business Address

Title/Rank/Grade

Business Phone Number 

Supervisor’s Phone Number

Start Date 

Previous Business Address

Title/Rank/Grade

Start Date/End Date

Date of Birth

Mother’s Maiden Name

Social Security Number                      Driver’s License Number and State

Home Phone

Number of Dependents         Ages    

Gross Annual Income $

Net Monthly Pay $

Other Income $ 

Are you self employed?   ❑ Yes   ❑ No

Current Employer

Type of Business 

Previous Employer

Business Address

 Title/Rank/Grade

Business Phone Number 

Supervisor’s Phone Number

Start Date 

Previous Business Address

Title/Rank/Grade

Start Date/End Date

LIST ALL DEBTS. Attach other sheets if necessary.                                             NOTE: Alimony, child support, or separate maintenance income need not be revealed if you do not choose to have it considered.

Debts

Owed to

Address 

Account No.              Present Balance      Monthly Payments      Amount Past Due

Mortgage or Rent

Second Mortgage

Auto Loan

Credit Card

Credit Card

Child Support,
Alimony or
Maintenance

Other

LIST ALL ASSETS. List all items you own free and clear on another sheet if necessary.

Home  ❑ Own  ❑ Rent

Years there

Estimated Market Value $

Auto License(s)    

Make of Auto                                 Year

Make of Auto                                   Year

Other/Describe                                                      Market Value $       Other/Describe                                                      Market Value $         Other/Describe                                                      Market Value $

1

2

Are you the comaker of any other loans?   ❑ Yes   ❑ No                

How much?                                                

For whom?

Have you ever filed for bankruptcy?   ❑ Yes   ❑ No

Are you a U.S. citizen?   ❑ Yes   ❑ No

Have you any legal proceedings against you?   ❑ Yes   ❑ No

FINANCIAL REFERENCES

Share Draft or Checking Account Number / Amount               Name and address of depository

Savings Account Number / Amount                                      Name and address of depository  

PERSONAL REFERENCES

Name and address of nearest relative not living with you

Name and address of a personal friend (not a relative)

Phone

Phone

Phone

Phone

Relationship

The credit union is relying on what you stated in this application, and you acknowledge that everything you have stated is true and correct and that you have provided a COMPLETE listing of all your debts and
obligations. You authorize the Credit Union to obtain credit reports in connection with this application for credit and for any update, increase, renewal, extension, or collection of the credit 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.    
By signing below, you acknowledge receipt of and agree to the terms of the Visa Credit Card Agreement that was attached to this application when you received it. Detach the Visa Credit Card Agreement and retain it
for your records.

Applicant Signature
X

Date

Co-Applicant Signature
X

Date

CREDIT UNION USE ONLY ❑ Approved     ❑ Rejected        Credit Limit $ _____________________      Visa Account Number _____________________     Member Credit Union Account Number ___________________

Conditions/Comments _____________________________________________________________________________________________________     Loan Officer ____________________________     Date _________________

DETACH AND RETURN THIS APPLICATION TO NORSTATE FEDERAL CREDIT UNION

INTEREST RATES AND INTEREST CHARGES

Annual Percentage Rate
(APR) for purchases

Credit Score
Annual
Percentage
Rate

A

B

C

D

10.9%

11.9%

12.9%

15.9%

We will tell you in writing which rate applies upon approval of your application. Rate based on credit score.

APR for Balance Transfers

The same Annual Percentage Rate listed for purchases above.

APR for Cash Advances

The same Annual Percentage Rate listed for purchases above.

Penalty APR and When It Applies

18.00% This APR may be applied to your account if you:
1) Make a late payment;
2) Go over your credit limit;
3) Make a payment that is returned; or
4) Do any of the above on another account that you have with us.
How Long Will the Penalty APR Apply? If your APR is increased for
any of these reasons, the Penalty APR will apply until (you make 6
consecutive minimum payments when due)

How to Avoid Paying
Interest on Purchases

Your due date is 25 days after the close of each billing cycle. We will  
not charge interest on purchases if you pay your entire balance by the 
due date each month.

Minimum Interest Charge

If you are charged interest, the charge will be no less than $1.50.

For Credit Card Tips from
the Federal Reserve Board

To learn more about factors to consider when applying for or using a 
credit card, visit the website of the Federal Reserve Board at
http://www.federalreserve.gov/creditcard.

FEES
· Annual Fee

Transaction Fees
· Balance Transfer
· Cash Advance

· Foreign Transaction Fees

None

None
None
1% for currency conversion. 0.8% for non-currency conversion.
$1.25 ATM cash disbursement fee at surcharge-free ATMs
$0.50 ATM cash disbursement fee at surcharge ATMs 

Please refer to Section 12, Foreign Transactions for more information.

Penalty Fees
· Late Payment
· Over-the-Credit Limit
· Returned Payment

$20
$10
$25

How We Will Calculate Your Balance: We use a method called “average daily balance (excluding new purchases).”
The information about the cost of the card described on this application was printed on January 11, 2012 and was accurate as of that date, but is subject to change
after that date. 

You should call the credit union at 207-728-7555 or write to: NorState Federal Credit Union, 78 Fox Street, Madawaska, ME 04756 for any changes in the information
about the cost of the card since the time of printing.

Billing Rights: Information on your rights to dispute transactions and how to exercise those rights is provided in your account agreement.