Credit Card Application Form – Fill Out and Use This PDF

VISA and MasterCardWest TexasConsumerNationalCreditBankCard Application

®®

❏ WE INTEND TO APPLY FOR JOINT CREDIT: _________ (Applicant Initials) _________ (Co-Applicant Initials)

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING AN 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 FOR YOU: When you open an account, we will ask for your 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.

MARRIED WI RESIDENTS: If you are applying for an individual account or a joint account with someone other than your spouse, and your spouse also lives in Wisconsin, combine your financial information with your spouse’s financial information. You understand that we may be required to notify your spouse of this

account. Married Wisconsin residents must furnish their (the applicant’s) name and social security number as well as the name and address of their spouse to TIB-The Independent BankersBank at P.O. Box 569120, Dallas, TXAPPLICANT75356-9120.

*ALIMONY, CHILD SUPPORT OR SEPARATE MAINTENANCECO-APPLICANT/SPOUSE/AUTHORIZEDINCOME NEED NOT BE REVEALED IF YOU DO NOT WISH T TO BE CONUSERID ED AS A BASIS FOR REPAYING THIS OBLIGATION.

Complete the following questions about your spouse only if you live in a community property state, or if you choose to rely on income or assets of your spouse. If you have a co-applicant or are requesting an authorization for a user of the Account, provide information about that person. If you are relying on alimony, child support, or separate maintenance payments or on the income or assets of another person, complete regarding that person.

*ALIMONY, CHILD SUPPORT OR SEPARATE MAINTENANCE INCOME NEED NOT BE REVEALED IF YOU DO NOT WISH IT TO BE CONSIDERED AS A BASIS FOR REPAYING THIS OBLIGATION.

LOAN APPLICATION CERTIFICATION: Everything that I/we have stated in this application is correct to the best of my/our knowledge. I/We understand that this application will remain your property and you will retain it whether or not this application is approved.

This application is submitted to obtain credit. You are authorized to check my/our employment history and to ask questions about my/our credit experiences. Without limiting the foregoing, I/we authorize you to make inquiries (including requesting reports from consumer credit reporting agencies and other sources) to verify my/our identity and determine my/our eligibility for credit, and subsequently in connection with any extension of credit, update, renewal, review or collection of my/our account or for any other legal purpose. I understand that, on my/our request, you will tell me/us whether or not you requested a credit report and the names and addresses of any credit bureaus that provided you such reports. I/We also authorize you to release information to others about my/our credit history with you. I/We understand that you may report information about my/our account to credit bureaus. Late payments, missed payments, or other defaults on my/our account may be reflected in my/our credit report.

STATE LAW DISCLOSURES: CA Residents: Regardless of your marital status, you may apply for credit in your name alone. If this is a joint account, after credit approval each applicant has the right to use

this account to the extent of any credit limit set by the creditor, and each applicant may be liable for all amounts of credit extended under this account to any joint applicant. DE and MD Residents: Service

charges not in excess of those permitted by law will be charged on the outstanding balances from month to month. NY Residents: New York residents may contract the New York State Banking Department

(1-800-518-8866) to obtain a comparative listing of credit card rates, fees, and grace periods. OH 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. Married WI residents: No provision of a marital property agreement, a unilateral statement under section 766.59, or a court decree under section 766.70 adversely affects the interest of the creditor unless the creditor, prior to the time the credit is granted, is furnished a copy of the agreement, statement, or decree or has actual knowledge of the adverse provision when the obligation to the credit is incurred.