CREDIT CARD APPLICATION 

P.O. Box 638 - Altus, Oklahoma 73522 
Date 

Account Number 

APPLICANT INFORMATION. Married Applicants may apply for an individual loan/separate account.  
Type of Credit. Check the type of credit for which you wish to apply. 

 Individual credit -- If you are applying for individual credit, complete the Applicant section.   
 Joint credit – If you are applying for joint credit with your spouse or another person, complete the Applicant section and the Spouse/Co-Applicant section. 

You must initial here if you intend to apply for Joint Credit:  X                             X                         _ 
Spouse Information. You must also complete the Spouse section if any of the following apply:  (1) your spouse will use your account; (2) you are relying on your spouse’s income as a source 
of repayment; (3) you live in a community property state (AZ, CA, ID, LA, NM, NV, TX, WA, WI or Puerto Rico); or (4) you are an Alaska resident and are currently subject to a community 
property agreement or community property trust. 

Credit Limit Requested:  $_________________          No. of Cards: _______ 
Authorized User Name: _______________________________________________________ 
You understand that by using the credit card (“card”), or allowing another to use the card; you agree that such use constitutes your acknowledgment, receipt and agreement to the terms and 
conditions of the credit card agreement provided to you in connection with the card or credit line. Refer to the separate table that includes required credit card disclosures being furnished with 
this Application. To obtain any change in the required information since it was printed, please call us at (866) 345-7965 or write to us at the address stated on this Application. 
Optional Payment Protection – If you answer “yes” the Credit Union will disclose the cost of optional payment protection to you. A separate election that discloses the terms and conditions 
must be signed for protection to become effective.   Are you interested in having this loan protected?   
APPLICANT     
Complete only if: (a) credit will be secured by collateral; or (b) you live in a community property 
state; or (c) you are an Alaska resident subject to a community property agreement or community 
property trust: 
 MARRIED    

Complete only if: (a) credit will be secured by collateral; or (b) you live in a community property 
state;  or  (c)  you  are  an  Alaska  resident  subject  to  a  community  property  agreement  or 
community property trust: 

 UNMARRIED (Single, Divorced, Widowed) 

 UNMARRIED (Single, Divorced, Widowed) 

 CO-APPLICANT  

 GUARANTOR 

 SPOUSE    

 SEPARATED     

 SEPARATED     

 MARRIED    

 Yes   

 No 

APPLICANT NAME 

SPOUSE/CO-APPLICANT NAME 

SOCIAL SECURITY NO. 

DRIVER’S LICENSE NO. & STATE 

BIRTH DATE 

SOCIAL SECURITY NO. 

DRIVER’S LICENSE NO. & STATE 

BIRTH DATE 

HOME PHONE NO. 

CELL PHONE* 

MOTHER’S MAIDEN NAME 

HOME PHONE NO. 

CELL PHONE* 

MOTHER’S MAIDEN NAME 

E-MAIL ADDRESS 

E-MAIL ADDRESS 

CURRENT STREET ADDRESS (Street/City/State/Zip) 

CURRENT STREET ADDRESS (Street/City/State/Zip) 

SINCE 

DO YOU: 

 OWN    

 RENT 

PERSONAL REFERENCE (Name and Address) 

RELATIONSHIP 

PERSONAL REFERENCE (Name and Address) 

PHONE NO. 

EMPLOYMENT & INCOME You need not list income from alimony, child support or separate maintenance unless you wish it considered for purposes of granting this credit. 
EMPLOYER (Name and Address) 

EMPLOYER (Name and Address) 

HIRE DATE 

WORK PHONE NO. 

SINCE 

DO YOU: 

 OWN    

 RENT 

RELATIONSHIP 

PHONE NO. 

HIRE DATE 

WORK PHONE NO. 

MONTHLY GROSS INCOME 

OTHER MONTHLY INCOME 

SOURCE 

MONTHLY GROSS INCOME 

OTHER MONTHLY INCOME 

SOURCE 

$ 

$ 

$ 

 No 

 Yes  

$ 
SIGNATURES – Are you currently on active military duty? 
You promise that the information stated in this Credit Card Application is true and correct to the best of your knowledge. You authorize the Credit Union to obtain credit reports when updating its records in connection with any 
review, increase, extension or renewal of credit, and in connection with any collection activities involving credit extended to you. The Credit Union may also obtain credit reports to update, increase, extend, renew or collection of 
the credit received by you. False or misleading statements in your application may cause any loan to be in default. You agree that this application shall be the Credit Union’s property whether or not this application is approved. 
You will notify the Credit Union in writing immediately of any changes in your name, address or employment. You understand that it is a federal crime to willfully and deliberately provide incomplete or incorrect information to 
obtain credit. If you request, you will be provided the name and address of any credit bureau from which we received a credit report. You understand and agree that if your application is approved, that any collateral described in 
any security agreement, pledge, advance disbursement voucher or similar document that may be executed, now or in the future, in connection with such credit will secure the Credit Union for repayment of funds advanced to you, 
subject to the terms and conditions of such security agreement, pledge, advance disbursement voucher or similar document. CONSENSUAL SECURITY INTEREST. You further acknowledge and agree that you give the 
Credit Union a consensual security interest in the shares you have in all individual and joint accounts you have with the Credit Union, now and in the future (other than those accounts that would have an 
adverse tax consequence if pledged as collateral), to secure repayment of amounts you owe to the extent of any unpaid balance on your Account. 
*Permission to Contact: By providing the Credit Union with a wireless phone number (cell phone), you consent to receiving calls, including autodialed and prerecorded messages from the Credit Union or 
its third party debt collector at that number. 
IMPORTANT  INFORMATION  ABOUT  PROCEDURES  FOR OPENING  A  NEW  ACCOUNT:  To  help  the  government  fight the  funding  of  terrorism  and  money  laundering  activities,  Federal  law  requires  all  financial 
institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other 
information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. 
OHIO RESIDENTS: The Ohio laws against discrimination requires that all creditors make credit equally available to all credit worthy 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. 
WISCONSIN RESIDENTS: For any provision of any marital property agreement, court decree under WI ST § 766.70, or statement under WI ST § 766.59 to adversely affect the rights of the Credit Union, the Credit Union 
must be provided with a copy of the Agreement, decree or statement or have actual knowledge of its terms before any credit is approved or account opened. Sign if you are NOT applying for this loan account with your 
spouse. This credit request, if approved, will be incurred in the interest of the marriage or family of the undersigned. 

Wisconsin Resident Signature _________________________________________________ Date __________________ 

X 
Applicant 
Credit Union Use Only 

Date 

X 
Spouse/Co-Applicant/Guarantor 

Date 

Approved 

 Yes   

 No, Reason _________________________________________________      No. of Cards: ______  Credit Limit:___________________   

 ECOA Notice and reason for Rejection sent or delivered on _________________     Loan Officer Signature__________________________________________________________Date _______________________ 

Copyright 2011 ConmarSystems, Peachtree City, GA  30269 – EFORM 21651-1 Rev. 10/19 

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CREDIT CARD SOLICITATION DISCLOSURE 

IF YOU ARE APPLYING FOR A CREDIT CARD, THE FOLLOWING IS YOUR REQUIRED DISCLOSURE INFORMATION - The information provided in this 
disclosure is accurate as of October 1, 2019. The information may have changed after that date. To find out what may have changed call us at (866) 345-7965 
or write us at 2721 N Main Street, PO Box 638, Altus, OK 73522. Before we approve you for a credit card, we will review your credit report, and the information 
you provide with your application to confirm that you meet the criteria for this offer. The full terms and conditions will be outlined in the Credit Card Agreement 
and Disclosure which will be sent to you with the new card(s). 

Interest Rates and Interest Charges 

ANNUAL PERCENTAGE RATE 
for Purchases 

10.75%-16.75% when you open your account, based on your creditworthiness. 
The APR will vary with market based on the Prime Rate. 

ANNUAL PERCENTAGE RATE 
for Balance Transfers 

16.75%  
The APR will vary with market based on the Prime Rate. 

ANNUAL PERCENTAGE RATE 
for Cash Advances 

16.75%   
The APR will vary with market based on the Prime Rate. 

Penalty APR and When it Applies 

How to Avoid Paying Interest 

17.00% 
This APR may be applied to your account if you: 
Are 60 days late in making a payment 

How Long Will the Penalty APR Apply? If your APR's are increased for any of these reasons, 
the Penalty APR will apply until you make three (3) consecutive minimum payments when due. 

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.  

Minimum Interest Charge 

None 

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  

Transaction Fees 

Cash Advance  
Foreign Transactions  

Penalty Fees 

Late Payment 
Returned Payment Fee 

None 

$5.00 or 1.00%, whichever is greater 
1% of each transaction in U.S. dollars 

Up to $20.00 
Up to $20.00 

How We Will Calculate Your Balance: We use a method called “Average Daily Balance (including new purchases)”. 

Application of Penalty APR. Your APR may be increased to the disclosed Penalty APR if you are 60 days late in making a payment. 

Late Payment Fee                                
Returned Payment Fee                      
Statement Copy Fee                         
Rush Fee                                         
Emergency Card Replacement Fee    
Card Replacement Fee                    

$20.00 or the amount of the required minimum payment, whichever is less, if you are ten (10) days or more late in making a payment. 
$20.00 or the amount of the required minimum payment, whichever is less. 
$  5.00 
$30.00 
$30.00 
$10.00 

Copyright 2011 ConmarSystems, Peachtree City, GA  30269 – EFORM 21651-1 Rev. 10/19 

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