130 23rd Ave SW 
Rochester, MN  55902 

507-535-1460 Tel 
800-535-2129 Toll Free 
www.mayocreditunion.org 

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, call us toll free at 800-535-2129 or 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 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.                                             
APPLICANT 
NAME (Last - First - Initial) 

  OTHER    
  NAME (Last - First - Initial) 

MOTHER’S MAIDEN NAME 

 Credit Limit Requested $ __________________ 

 CO-APPLICANT    

 SPOUSE    

 GUARANTOR 
MOTHER’S MAIDEN NAME 

ACCOUNT NUMBER 

SOCIAL SECURITY NUMBER 

  ACCOUNT NUMBER 

SOCIALSECURITY NUMBER 

DRIVER’S LICENSE NUMBER / STATE 

EMAIL ADDRESS 

  DRIVER’S LICENSE NUMBER / STATE 

EMAIL ADDRESS 

BIRTH DATE                        HOME PHONE                             BUSINESS PHONE / EXT. 

  BIRTH DATE                        HOME PHONE                             BUSINESS PHONE / EXT. 

PRESENT ADDRESS (Street - City - State - Zip) 

 OWN  

 RENT 

  PRESENT ADDRESS (Street - City - State - Zip) 

 OWN  

 RENT 

LENGTH AT RESIDENCE 

LENGTH AT RESIDENCE 

MORTGAGE / RENT OWED TO: 

  MORTGAGE / RENT OWED TO: 

MORTGAGE BALANCE                      MONTHLY PAYMENT                             INTEREST RATE 

  MORTGAGE BALANCE                      MONTHLY PAYMENT                             INTEREST RATE 

$                                                           $                                                                                        % 
COMPLETE FOR JOINT CREDIT OR IF YOU LIVE IN A COMMUNITY PROPERTY STATE:  

$                                                           $                                                                                        % 

  COMPLETE FOR JOINT CREDIT OR IF YOU LIVE IN A COMMUNITY PROPERTY STATE:   

 MARRIED  

 SEPERATED  

 UNMARRIED (Single - Divorced - Widowed) 

 MARRIED  

 SEPERATED  

 UNMARRIED (Single - Divorced - Widowed) 

EMPLOYMENT / INCOME 
NAME   AND  ADDRESS  OF EMPLOYER 

  EMPLOYMENT / INCOME 
  NAME  AND  ADDRESS  OF EMPLOYER 

JOB TITLE 

HOURS AT WORK 

START DATE 

JOB TITLE 

HOURS AT WORK 

START DATE 

NOTICE:  ALIMONY, CHILD SUPPORT, OR SEPARATE MAINTENANCE INCOME NEED NOT BE  
                    REVEALED IF YOU DO NOT CHOOSE TO HAVE IT CONSIDERED. 
EMPLOYMENT INCOME 

OTHER INCOME 

  NOTICE:  ALIMONY, CHILD SUPPORT, OR SEPARATE MAINTENANCE INCOME NEED NOT BE  
  EMPLOYMENT INCOME 

                    REVEALED IF YOU DO NOT CHOOSE TO HAVE IT CONSIDERED. 
OTHER INCOME 

$     

PER 

$  

PER 

$ 

PER 

$ 

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. 

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 unless the Credit Union is 

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 any future update, renewal or extension 
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.    It  is  a  federal  crime  to  willfully  and 
deliberately provide incomplete or incorrect information on loan applications made to 
federal credit unions or state chartered credit unions insured by NCUA. 

  2.  You understand that the use of your card will 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 

  X 

     APPLICANT’S SIGNATURE                                                                           DATE 
© CUNA MUTUAL GROUP, 2009, ALL RIGHTS RESERVED                                                                                                                                                                                                                    (AXC000)-e

     OTHER SIGNATURE                                                                                         DATE 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
130 23rd Ave SW 
Rochester MN 55902 
507-535-1460  
800-535-2129 
www.mayocreditunion.org  

Interest Rates and Interest Charges  
Annual Percentage Rate (APR) for 
Purchases  

                VISA CLASSIC, VISA SECURED 
                       AND VISA PLATINUM 

APPLICATION AND SOLICITATION DISCLOSURE             

Visa Classic and Visa Secured 

12.00% - This APR will vary with the market based on the Prime Rate.  
.  

Visa Platinum  

8.00% - This APR will vary with the market based on the Prime Rate.  

APR for Cash Advances  

Visa Classic and Visa Secured 

12.00% - This APR will vary with the market based on the Prime Rate.  

8.00% - This APR will vary with the market based on the Prime Rate.  

Visa Platinum  

APR for Balance Transfers  

Visa Classic and Visa Secured 

12.00% - This APR will vary with the market based on the Prime Rate.  

8.00% - This APR will vary with the market based on the Prime Rate.  

Visa Platinum  

Your due date is at least 25 days after the close of each billing cycle. We do 
not charge you interest on purchases if you pay your entire balance by the due 
date each month.  
To learn more about factors to consider when applying for or using a credit 
card, visit the Web site of the Consumer Financial Protection Bureau at 
http://www.consumerfinance.gov/learnmore.  

1.00% of each transaction in U.S. dollars  

Up to $25.00  
Up to $25.00  

How to Avoid Paying Interest on 
Purchases  

For Credit Card Tips from the 
Consumer Financial Protection 
Bureau  
Fees  
Transaction Fees  
> Foreign Transaction Fee  
Penalty Fees  
> Late Payment Fee  
> Returned Payment Fee  

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 1, 2017. 
This information may have changed after that date. To find out what may have changed, contact the Credit Union.  

OTHER DISCLOSURES 

Statement Copy Fee 
Rush Fee 
Card Replacement Fee   

$ 5.00    
$30.00   
$10.00   

Late Payment Fee 

$25.00 or the amount of the required minimum 
            payment, whichever is less. 

Returned Payment Fee  $25.00 or the amount of the required minimum 

             payment, whichever is less. 

© CUNA MUTUAL GROUP, 2009, ALL RIGHTS RESERVED                                                                                                                                                                              DMNS10 (MXC400 CCM000)-e