CREDIT CARD
APPLICATION

There are costs associated with the use of a credit card. Information about costs, rates and fees may be contained in disclosures provided with this

application or by calling us toll-free or collect at

or writing 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.
2.
3.

you live in or the property pledged as collateral is located in a community property state (AK, AZ, CA, ID, LA, NM, NV, TX, WA, WI)
your spouse will use the account, or
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.
Credit Card Account:

 Individual

 Joint

If this is an application for joint credit, Applicant and Co-Applicant each agree and acknowledge the intent to apply for joint credit (sign below):

Applicant

X

Date

Co-Applicant

(Seal)

X

 Credit Limit Requested $

If Authorized User, Name:

APPLICANT

NAME (Last - First - Initial)

Guarantors Complete OTHER section below.
OTHER
NAME (Last - First - Initial)

CO-APPLICANT

SPOUSE

Date

(Seal)

GUARANTOR

OTHER

ACCOUNT NUMBER

SOCIAL SECURITY NUMBER

ACCOUNT NUMBER

SOCIAL SECURITY NUMBER

BIRTH DATE

EMAIL ADDRESS

BIRTH DATE

EMAIL ADDRESS

HOME PHONE

CELL PHONE

BUSINESS PHONE/EXT.

HOME PHONE

CELL PHONE

BUSINESS PHONE/EXT.

DRIVER’S LICENSE NUMBER/STATE

AGES OF DEPENDENTS

DRIVER’S LICENSE NUMBER/STATE

AGES OF DEPENDENTS

PRESENT ADDRESS (Street – City – State – Zip)

OWN

RENT

PRESENT ADDRESS (Street – City – State – Zip)

OWN

RENT

LENGTH AT RESIDENCE

LENGTH AT RESIDENCE

PREVIOUS ADDRESS (Street – City – State – Zip)

OWN

RENT

PREVIOUS ADDRESS (Street – City – State – Zip)

OWN

RENT

LENGTH AT RESIDENCE

LENGTH AT RESIDENCE

MORTGAGE/RENT OWED TO

MORTGAGE/RENT OWED TO

MORTGAGE BALANCE
$
COMPLETE FOR JOINT CREDIT, SECURED CREDIT OR IF YOU LIVE IN A COMMUNITY
PROPERTY STATE:

MONTHLY PAYMENT
$

INTEREST RATE

%

MORTGAGE BALANCE
$
COMPLETE FOR JOINT CREDIT, SECURED CREDIT OR IF YOU LIVE IN A COMMUNITY
PROPERTY STATE:

MONTHLY PAYMENT
$

INTEREST RATE

%

MARRIED

SEPARATED

UNMARRIED (Single - Divorced - Widowed)

MARRIED

SEPARATED

UNMARRIED (Single - Divorced - Widowed)

EMPLOYMENT/INCOME

START DATE

EMPLOYMENT/INCOME

START DATE

EMPLOYMENT STATUS

FULL TIME

PART TIME

EMPLOYMENT STATUS

FULL TIME

PART TIME

NAME AND ADDRESS OF EMPLOYER

NAME AND ADDRESS OF EMPLOYER

NOTICE: ALIMONY, CHILD SUPPORT, OR SEPARATE MAINTENANCE INCOME NEED NOT
BE REVEALED IF YOU DO NOT CHOOSE TO HAVE IT CONSIDERED.

NOTICE: ALIMONY, CHILD SUPPORT, OR SEPARATE MAINTENANCE INCOME NEED NOT
BE REVEALED IF YOU DO NOT CHOOSE TO HAVE IT CONSIDERED.

EMPLOYMENT INCOME
$

PER

TITLE/GRADE

OTHER INCOME
$

SOURCE

PER

EMPLOYMENT INCOME
$
TITLE/GRADE

PER

OTHER INCOME
$

SOURCE

PER

PREVIOUS EMPLOYER NAME AND ADDRESS IF EMPLOYED LESS THAN FIVE YEARS

PREVIOUS EMPLOYER NAME AND ADDRESS IF EMPLOYED LESS THAN FIVE YEARS

STARTING DATE

ENDING DATE

STARTING DATE

ENDING DATE

© CUNA Mutual Group 2016 All Rights Reserved

00910226-AXX00-C-1-071117 (AXX001-E)

MILITARY: IS DUTY STATION TRANSFER EXPECTED DURING NEXT YEAR?

YES

 NO MILITARY: IS DUTY STATION TRANSFER EXPECTED DURING NEXT YEAR?

YES

NO

WHERE

ENDING/SEPARATION DATE

WHERE

ENDING/SEPARATION DATE

CONSENT TO CONTACT

BY SIGNING BELOW, YOU AUTHORIZE 121 FINANCIAL CREDIT UNION TO DELIVER OR CAUSE TO BE DELIVERED TO YOU AT THE
TELEPHONE NUMBERS PROVIDED ABOVE, ADVERTISING AND TELEMARKETING CALLS AND TEXT MESSAGE(S) USING AN AUTOMATIC
TELEPHONE DIALING SYSTEM AND/OR AN ARTIFICIAL OR PRERECORDED VOICE. YOU ARE NOT REQUIRED TO SIGN THIS
AUTHORIZATION OR ENTER INTO THIS AGREEMENT AS A CONDITION OF PURCHASING ANY PROPERTY, GOODS OR SERVICES. You may
withdrawal the consent provided herein at any time by providing written notice to us at Attn: Risk Management, PO Box 40769, Jacksonville, Fl 32203,
by email at ask121@121fcu.org, via phone at 904-723-6300 or by any other reasonable means.

Applicant’s Signature

Date

Other Signature

X

(Seal)

X

Date

(Seal)

By executing this application, you agree we and/or our third-party vendors (including debt collectors) may contact you by telephone or text message at
any telephone number associated with your account, including wireless telephone numbers (i.e. cell phone numbers) which could result in charges to
you, in order to service your account or collect any amounts owed to us, excluding any contacts for advertising and telemarketing purposes as
prescribed by law. You further agree methods of contact may include use of pre-recorded or artificial voice messages, and/or use of an automatic dialing
device. You may withdraw the consent to be contacted on your wireless telephone number(s) at any time by written notice to us at Attn: Risk
Management, PO Box 40769, Jacksonville, FL 32203, by email to ask121@121fcu.org, via phone at (904) 723-6300 or by any other reasonable means.
If you have provided a wireless telephone number(s) on or in connection with this application, you represent and agree you are the wireless subscriber
or customary user with respect to the wireless telephone number(s) provided and have the authority to give this consent. Furthermore, you agree to
notify us of any change to the wireless telephone number(s) for which you are providing your consent to be contacted. You agree to indemnify us and
our third-party vendors, and hold us and our third-party vendors, harmless, from and against any and all losses, claims, damages, liabilities, costs of
expenses (including attorney’s fees) that arise out of your breach of any of the foregoing representations and agreements.

In order to help mitigate harm to you and your account, we may contact you on any telephone number associated with your account, including a wireless
telephone number (i.e. cell phone number), to deliver to you any messages related to suspected or actual fraudulent activity on your account, data
security breaches or identity theft following a data breach, money transfers, or any other exigent messages permitted by applicable law. These contacts
will not contain any telemarketing, cross-marketing, solicitation, advertising, or debt collection message of any kind. The contacts will be concise and
limited in frequency as required by law. You will have an opportunity to opt-out of such communications at the time of delivery.

STATE LAW NOTICE(S)
Notice to Nebraska Residents: A credit agreement must be in writing to be enforceable under Nebraska law. To protect you and us from any
misunderstandings or disappointments, any contract, promise, undertaking, or offer to forebear repayment of money or to make any other financial
accommodation in connection with this loan of money or grant or extension of credit, or any amendment of, cancellation of, waiver of, or substitution for
any or all of the terms or provisions of any instrument or document executed in connection with this loan of money or grant or extension of credit, must
be in writing to be effective.
Notice to New York Residents: New York residents may contact the New York State Department of Financial Services to obtain a comparative listing
of credit card rates, fees, and grace periods. New York State Department of Financial Services: 1-800-342-3736 or www.dfs.ny.gov.
Notice to Ohio Residents: 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.
Notice to Wisconsin Residents: (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 121 Financial Credit Union unless 121 Financial Credit Union is 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.

Signature for Wisconsin Residents Only

X

Date

(Seal)

00910226-AXX00-C-1-071117 (AXX001-E)

CONSENSUAL SECURITY INTEREST
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. Shares and deposits in an IRA or 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. You may withdraw these other shares
unless you are in default. When you are in default, you authorize us to apply the balance in these accounts to any amounts due. For example,
if you have an unpaid credit card balance, you agree we may use funds in your account(s) to pay any or all of the unpaid balance.

By signing or otherwise authenticating below, you are affirmatively agreeing that you are aware that granting a security interest is a condition
for the credit card and you intend to grant a security interest. You acknowledge and agree that your pledge does not apply during any
periods when you are a covered borrower under the Military Lending Act. For clarity, you will not be deemed a covered borrower, and your
pledge will apply, if: (i) you become obligated on a credit transaction or establish an account for credit when you are not a covered borrower;
or (ii) you cease to be a covered borrower.

Security Interest Acknowledgement and Agreement

Date

Security Interest Acknowledgement and Agreement

Date

X

(Seal)

X

(Seal)

SIGNATURES
By signing or otherwise authenticating below:
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 121 Financial 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 also authorize 121 Financial Credit Union to investigate and
verify any information provided in connection with this application including current and previous employment. You understand that 121 Financial
Credit Union will rely on the information in this application and your credit report to make its decision. If you request, 121 Financial 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 crime to willfully and deliberately provide
incomplete or incorrect information in this application.
You understand that the use of your card will constitute acknowledgment of receipt and agreement to the terms of the Consumer Credit Card
Agreement and Disclosure.

2.

Applicant’s Signature

Date

Other Signature

X

(Seal)

X

CREDIT UNION USE ONLY
DATE

APPROVED

NUMBER OF CARDS

DECLINED

Signatures

X

CREDIT LIMIT
$

CREDIT CARD NUMBER

Date

(Seal)

X

Date

(Seal)

Date

(Seal)

00910226-AXX00-C-1-071117 (AXX001-E)