Credit Card Application
A table
is on a
card disclosures
separatedocument provided with this Application. To obtain any change in
therequired information since it was printed, write to us at
the
addressstated on this Application.

required credit

includes

that

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 or the property pledged as collateral is located 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.

Credit Limit Requested $

APPLICANT

NAME (Last - First - Initial)

OTHER

NAME (Last - First - Initial)

CO-APPLICANT

SPOUSE

OTHER

ACCOUNT NUMBER

SOCIAL SECURITY NUMBER

ACCOUNT NUMBER

SOCIAL SECURITY NUMBER

DRIVER'S LICENSE NUMBER/STATE

EMAIL ADDRESS

DRIVER'S LICENSE NUMBER/STATE

EMAIL ADDRESS

BIRTH DATE

HOME PHONE

CELL PHONE

BUSINESS PHONE/EXT.

BIRTH DATE

HOME PHONE

CELL PHONE

BUSINESS PHONE/EXT.

PRESENT ADDRESS (Street - City - State - Zip)

OWN

RENT

LENGTH AT RESIDENCE

PRESENT ADDRESS (Street - City - State - Zip)

OWN

RENT

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
%

UNMARRIED (Single - Divorced - Widowed)

SEPARATED

MARRIED

MORTGAGE BALANCE
$
COMPLETE FOR JOINT CREDIT, SECURED CREDIT OR IF YOU LIVE IN A COMMUNITY PROPERTY
STATE:

MONTHLY PAYMENT
$

INTEREST RATE
%

UNMARRIED (Single - Divorced - Widowed)

SEPARATED

MARRIED

EMPLOYMENT/INCOME

START DATE

EMPLOYMENT/INCOME

START DATE

NAME AND 
ADDRESS OF 
EMPLOYER

NAME AND
ADDRESS OF 
EMPLOYER

NOTICE: ALIMONY, CHILD SUPPORT, OR SEPARATE MAINTENANCE INCOME NEED NOT BE

NOTICE: ALIMONY, CHILD SUPPORT, OR SEPARATE MAINTENANCE INCOME NEED NOT BE

REVEALED IF YOU DO NOT CHOOSE TO HAVE IT CONSIDERED.

REVEALED IF YOU DO NOT CHOOSE TO HAVE IT CONSIDERED.

EMPLOYMENT INCOME

$_____________ Per ______________

OTHER INCOME
$_____________ Per ______________

EMPLOYMENT INCOME
$_____________ Per _____________

OTHER INCOME
$_____________ 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.

unless the 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.

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

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
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. It is a crime to
willfully and deliberately provide incomplete or incorrect information in this
application. You also authorize the credit union to investigate and verify
any information provided in connection with this application including
current and previous employment.

of your

the use

card will

understand that

2. You
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

APPLICANT'S SIGNATURE

(SEAL)

X

DATE

OTHER SIGNATURE

CREDIT UNION USE ONLY

(SEAL)

DATE

APPROVED

NO. OF CARDS

CREDIT LIMIT $

CREDIT CARD NUMBER

DECLINED

CREDIT COMMITTEE OR LOAN OFFICER SIGNATURE

CUNA Mutual Group 2009 All Rights Reserved

00910226-AXC00-C-1-05142015 (AXC002)-e

Interest Rates and Interest Charges 
Annual Percentage Rate (APR) for 
Purchases 

APR for Balance Transfers 

APR for Cash Advances 

VISA PLATINUM/VISA PLATINUM REWARDS/VISA SIGNATURE
F1  
APPLICATION AND SOLICITATION DISCLOSURE 

Visa Platinum 
9.74% 11.99% 14.40% 14.49%
    , F4
F2
14.89%
F6
creditworthiness.

, F3
when you open your account, based on your 

, F5

, or

Visa Platinum Rewards 
10.24% 11.24% 12.24% 15.24%
F7
    , F9
17.24%
F11
creditworthiness. This APR will vary with the market based on the 
Prime Rate.

, F8
when you open your account, based on your 

, F10

, or

, F13       , F14
when you open your account, based on your 

Visa Signature 
11.24% 12.24% 15.24% 16.24%
F12
17.24%
F16
creditworthiness. This APR will vary with the market based on the 
Prime Rate.
Visa Platinum 
9.74% 11.99% 14.40% 14.49%
F17        , F18    
, F19     
your account, based on your creditworthiness.

, F15  

14.89%

, F20

, or F21        when you open 

, or

Visa Platinum Rewards 
10.24% 11.24% 12.24% 15.24%
F22      
, F24        , F25     
, F23    
your account, based on your creditworthiness. This APR will vary with 
the market based on the Prime Rate.

, or F26    when you open 

17.24%

, F29        , F30

Visa Signature 
11.24% 12.24% 15.24% 16.24%
F27        , F28    
your account, based on your creditworthiness. This APR will vary with 
the market based on the Prime Rate.
Visa Platinum 
9.74% 11.99% 14.40% 14.49%
F32        , F33     
your account, based on your creditworthiness.

, or F31    when you open 

, or F36     when you open 

, F34        , F35

14.89%

17.24%

Visa Platinum Rewards 
10.24% 11.24% 12.24% 15.24%
F37      
your account, based on your creditworthiness. This APR will vary with 
the market based on the Prime Rate.

, or F41        when you open 

, F38        , F39        , F40

17.24%

Visa Signature 
11.24% 12.24% 15.24% 16.24%
F42        , F43    
your account, based on your creditworthiness. This APR will vary with 
the market based on the Prime Rate.

, F45        , or F46      when you open 

, F44     

17.24%

©CUNA Mutual Group 2009, 10, 12 All Rights Reserved 

00910226-MXC40-C-1-010517 (MXC403 CCM003)-e

SEE NEXT PAGE for more important information about your account. 

 
Penalty APR and When it Applies 

17.90%
F47          

This APR may be applied to your account if you:

- Make a late payment

How Long Will the Penalty APR Apply? If your APRs are increased 
for this reason, the Penalty APR will apply until you make six
consecutive minimum payments when due.

How to Avoid Paying Interest on Purchases  Your due date is at least 25 days after the close of each billing cycle. 

For Credit Card Tips from the Consumer 
Financial Protection Bureau 

Fees 
Annual Fee 
- Annual Fee - Visa Platinum
- Annual Fee - Visa Platinum Rewards
- Annual Fee - Visa Signature
Transaction Fees 
- Balance Transfer Fee
- Cash Advance Fee – Visa Platinum and Visa 

Platinum Rewards

- Cash Advance Fee – Visa Signature

- Foreign Transaction Fee – Visa Platinum and

Visa Platinum Rewards

- Foreign Transaction Fee – Visa Signature
Penalty Fees 
- Late Payment Fee
- Over-the-Credit Limit Fee
- Returned Payment Fee

We will not charge you any 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 website of the Consumer Financial 
Protection Bureau at http://www.consumerfinance.gov/learnmore. 

None
F48          
None
F49          
$75.00
F50          

None
F51          
2.00%
$5.00
F52      or F53        of the amount of each cash advance, whichever is 
greater (Maximum Fee: F54   
3.00%
$10.00
F55       or F56        of the amount of each cash advance, whichever is 
$500.00
greater (Maximum Fee: F57      )
1.00%
F58      of each transaction in U.S. dollars

$500.00

)

None
F59          

$25.00

Up to F60          
None
F61          
Up to F62          

$25.00

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.

Effective Date:  
The information about the costs of the card described in this application is accurate as of F63                           .
This information may have changed after that date. To find out what may have changed, contact the Credit Union.

January 1, 2017

OTHER DISCLOSURES 

Late Payment Fee

Returned Payment Fee

Returned Convenience Check Fee

Statement Copy Fee
Document Copy Fee
Rush Fee
Card Replacement Fee
Pay-by-Phone Fee

$25.00
F64        or the amount of the required minimum payment, whichever is 
less, if you are five or more days late in making a payment.
$25.00
F65      or the amount of the required minimum payment, whichever is 
less.
$27.00
F66        or the amount of the returned convenience check, whichever is 
less.
$5.00
F67        per page
$2.00
F68       per document
$50.00
F69        2nd day
$10.00
F70          
$5.00
F71          

00910226-MXC40-C-1-010517 (MXC403 CCM003)-e