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C

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CREDIT APPLICATION
VISA® CLASSIC 

ACCOUNT TYPE
(Check Only One)

 INDIVIDUAL ACCOUNT
 JOINT ACCOUNT

CREDIT DISCLOSURES

ANNUAL 
PERCENTAGE RATE 
FOR PURCHASES, 
CASH ADVANCE & 
BALANCE TRANSFER

15.96%

VARIABLE RATE
INFORMATION

GRACE 
PERIOD

The annual percentage rate may vary 
semi-annually beginning april 1, 2010. 
The variable rate will BE 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%.

25
DAYS*

METHOD OF 
COMPUTING
THE BALANCE
FOR PURCHASES

AVERAGE 
DAILY
BALANCE
INCLUDING 
NEW
PURCHASES*

TELEPHONE
PAYMENT
FEE

ANNUAL
MEMBERSHIP 
FEE

LATE
PAYMENT
FEE

CASH 
ADVANCE 
FEE

MINIMUM
FINANCE
CHARGE

OVER
CREDIT
LIMIT 
FEE

LOST/
STOLEN
CARD 
FEE

BALANCE
TRANSFER
FEE

$10 PER 
OCCURRENCE

$0

$20

$0

$0

$0

$20

$0

The information about the costs of the card 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 this card, contact: Pinnacle Bank, PO Box 461209, Papillion, NE 68046, (402) 339-3244 or 1-800-369-7283 (RATE).

*A Finance Charge will be imposed on Credit Purchases only if you elect not to pay the entire New Balance shown on your monthly statement for the previous billing cycle within 25 days from the closing 
date of that statement. If you elect not to pay the entire New Balance shown on your previous monthly statement within that 25-day period, a Finance Charge will be imposed on the unpaid average daily 
balance of such Credit Purchases from the previous statement closing date and on new Credit Purchases from the date of posting to your account during the current billing cycle, and will continue to accrue 
until the closing date of the billing cycle preceding the date on which the entire New Balance is paid in full or until the date of payment if more than 25 days from the closing date.

The Finance Charge for a billing cycle is computed by applying the monthly Periodic Rate to the average daily balance of Credit Purchases, which is determined by dividing the sum of the daily balances 
during the billing cycle by the number of days in the cycle. Each daily balance of Credit Purchases is determined by adding to the outstanding unpaid balance of Credit Purchases at the beginning of the 
billing cycle any new Credit Purchases posted to your account, and subtracting any payments as received and credits as posted to your account, but excluding any unpaid Finance Charges. VISA® cards may 
not be used for any illegal transaction.

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? 

CREDIT CARD INSURANCE

$

$

$

$

$

$

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 

Form C485 8/01

SIGNATURE(S)

 NO, I do not want to protect 
my account in the event of death, 
disability or unemployment

Policy Forms 10085 Rev/11006 Rev.

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