Credit Card Application

* Required Fields

Credit Limit Requested:

Choose Visa:

Classic

Gold

Platinum

Account Type:

Individual Account

Joint Account

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 to you: When you open an Account, we will ask for our 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.

APPLICANT

Note: All applicable sections should be filled out completely to avoid delay in processing your application.

Last Name:

First Name:

Middle Name:

Social Security Number:

- -

Date of Birth:

Home Phone Number:

Cell Phone Number:

Email:

Do you:

Own

Rent

Other

Monthly Payment:

Current Address:

Current Address 2:

City:

State:

ZIP:

How Long (yrs):

Previous Address (if less than 2 years at present address):

Previous Address (if less than 2 years at present address) 2:

City:

State:

ZIP:

How long (yrs):

Employer Name:

Self Employed:

Yes

Work Phone:

Date Employed:

Employer Address:

Employer Address 2:

City:

State:

ZIP:

Position/Occupation:

Monthly Gross Income:

Name and Address of Previous Employer (if less than 2 years at present employer):

Name and Address of Previous Employer (if less than 2 years at present employer) 2:

City:

State:

ZIP:

How long (yrs):

Source of Additional Income: Income from alimony, child support or separate maintenance need not be revealed if it is not considered in determining creditworthiness.

No. of Dependents:

Amount per Month:

Nearest Relative (Not Living With You):

Home Phone:

Relationship:

Their Address:

Their Address 2:

City:

State:

ZIP:

CO-APPLICANT

Information about co-applicant is not required for an individual account.

Last Name:

First Name:

Middle Name:

Social Security Number:

- -

Date of Birth:

Home Phone Number:

Cell Phone Number:

Email:

Do you:

Own

Rent

Other

Monthly Payment:

Current Address:

Current Address 2:

City:

State:

ZIP:

How Long (yrs):

Previous Address (if less than 2 years at present address):

Previous Address (if less than 2 years at present address) 2:

City:

State:

ZIP:

How long (yrs):

Employer Name:

Self Employed:

Yes

Work Phone Number:

Date Employed:

Employer Address:

Employer Address 2:

City:

State:

ZIP:

Position/Occupation:

Monthly Gross Income:

Source of Additional Income: Income from alimony, child support or separate maintenance need not be revealed if it is not considered in determining creditworthiness.

No. of Dependents:

Amount per Month:

CREDIT INFORMATION

Upload Additional Documents If Necessary

Home Mortgage/Rent

Name and Address of Creditor:

Name under Which Account is Carried:

Account Number:

Balance:

Monthly Payment:

Bank Credit Card/Bank Name and Address

Name under Which Account Is Carried:

Account Number:

Balance:

Monthy Payment:

Upload Additional Information:

Credit Disclosures	Classic	Gold	Platinum
Annual Percentage Rate (APR) for Purchases (Variable	13.99%	11.99%	6.87%
Cash Advance APR (Variable)	19.99%	17.99%	10.87%
Balance Transfer APR (Fixed)	13.99%	11.99%	6.87%
Penalty APR 11.99%	19.99%	17.99%	11.99%
Grace Period for re-payment of balances for purchases	25 Days	25 Days	25 Days
Minium Finance Charge	$5.00	$5.00	$5.00
Return Payment Fee	$25.00	$25.00	$25.00
Transaction Fee for Cash Advances	$25.00	$25.00	$25.00
Late Payment Fee	$25.00	$25.00	$25.00
Over-the-Credit-Limit Fee	$25.00	$25.00	$25.00

The prime rate used to determine your APR is the rate published in the Wall Street Journal on the 2nd day of the prior month.
KY, OH, MI, TN Fees Disclosed and Calculated as Finance Charge.

SIGNATURES

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 cardholder 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 persumed 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. we may report information about your account to the credit bureau. Late payments, missed payments, or other defaults on your account may be reflected in your credit report.

Applicant Signature
Date

Co-Applicant Signature
Date

TRANSFER OF BALANCE REQUEST

Upon approval, I wish to transfer my present balance on the credit card account(s) listed below to my new credit card account

Credit Card Account Number:

Amount to be transferred:

Security Code:

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