Personal Gold Card Application

Check Account Choice:
CREDIT APPLICATION
(Signature
Credit Limit Requested $
required
8
Individual Account
Joint Acccunt
We inlend to apply for joinl credil
ApplicanllnRials
C<>-ApplicantInRiais
OCredR line Increase
for joint applicant)
_
0 Visa& Gold
Check Card Choice
_
0 Gold MasterCard"
IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT: To help the government fight the funding of terrorism and money laundering activities, Federal laws require all financial
institutions to obtain, verify and record information that identifies each person who opens an Account. Whal U,is means to you: When you open an Account, we will ask for your name, address, date of birth, and other
information that will allow us to identifv vou We mav also ask to see your driver's license or other identifyino documents.
Last Name
First
Middle
Social Security Number
f
~g
0;;::::
I
Date of Birth
No. of Dependents
romethone
fell prone
Own
Rent
Other
0
0
0
Monthly Payment $
Current Address
City
State
Zip Code
How Long (yrs)
"'a.
~~
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Mailing Address (if different from above)
City
State
Zip Code
How Long (yrs)
Previous Address (if less than 2 years at present address)
City
State
Zip Code
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Employer
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Address
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Self Employed
OYes ONo
How Long (yrs)
Work Phone
(
)
Date Employed
Position/Occupation
Monthly Gross Income $
Name and Address of Previous Employer (if less than 2 years at present employer)
How Long (yrs)
of Additional Income: Income from alimony, child support or separate
maintenance need not be revealed if it is not considered in determining creditworthiness
Amount per Monlh $
!~
~.9
Source
~
0
z
Nearest Relative (Not Living With You)
last Name
I-:E~
Date of Birth
-e ffial-'
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Current Address
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Previous
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First
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No. of Dependents
Address (if less than 2 years at present address)
Home Phone
(
)
City
~omethone
Relationship
Middle
Social Security Number
Own
fell p)hone
City
I OYes
Self Employed
0 No
Employer
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2. Bank Credit CardlBank
u
Monthly Payment $
Zip Code
How Long (yrs)
Zip Code
How Long (yrs)
Date Employed
jhOne
Monlhly Gross Income $
Position/Occupation
Name and Address of Creditor
1. Home Mortgage/Rent
Other
State
Source of Additional Income: Income from alimony, child support or separate
maintenance need not be revealed if it is not considered in determinina creditworthiness
ft", :.
0
State
fork
Address
Rent
Amount per Month $
Name under Which Account is Carried
Account Number
Balance
Monthlv Payment
Name and Address
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CHARGEGARD INSURANCE PROTECTION REQUEST RI, NV, AZ, MD, PA, NY, AK & VA residents: Please contact this institution to obtain the insurance application applicable to your state.
By electing optional Chargegard insurance, I acknowledge that Chargegard includes credit life, disability, involuntary unemployment, and leave of absence to the extent available in my state as
described in the Summary of Insurance. I read and I meet the age eligibility requirements shown in the Summary of Insurance'. Monthly premium charges are based on the account balance and the rate
shown, I may cancel anytime. 'Please see the Summary of Insurance on the back.
Yes, please enroll me in Chargegard Credit Insurance
X
N1991-0299 NonStd 10#19
Sianature
Date of Birth
Date
PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING: This statement is submitted to obtain credit and IIwe certify that all information herein is true and complete. l!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. lIWe
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 presumed by the applicant's use. If you intend to apply for jOint credit, 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 bureaus. Late payments, missed payments, or other defaults on your account may be reflected in your credit report.
X
Date
Aoolicant Sianature
-
X
Co-Aoolicant
Date
Sianature
Upon approval, I wish to transfer my present balance on the credit card account(s) listed below to my new credit card account.
ffi...Jtu..«ffi
encc:;) Cl Credit Card Account
Zu..O'
~OW
t- ~ Signature
~~ Visa Account No.
~zz
O~O
u..wW
t-(I) Date Approved
Number
Amount to be transferred
$
MasterCard Account No.
I
Credit Line
Approved By
Date Approved
Credit Line
Approved By
Z;:)
Elkhorn Falley Balik and Trust, Norfolk, NE 68702-1007
FOLD AND SECURE WITH TAPE FOR MAILING
Big Red Printing
All contents are accurate at the time of printing, for changes that may have been made after priming please call (877) 644-0900.
I
Interest Rates and Interest Charges
Visa" Gold
Gold MasterCard"
Annual Percentage Rate (APR) for Purchases
12.900/0
12.900/0
Fixed
Fixed
APR for Balance Transfers
12.900/0
12.900/0
Fixed
Fixed
APR for Cash Advances
12.900/0
12.900/0
Fixed
Fixed
Penalty APR and When it Applies
None
How to Avoid Paying Interest
Your due date is at least 25 days after the close of each billing cycle. We will not charge you
interest on retail purchases if you pay your entire balance by the due date. We will begin
charging interest on cash advances and/or balance transfers on the transaction date.
Minimum Interest Charge
If you are charged interest, the charge will be no less than $1.00.
For Credit Card Tips from the Consumer Financial
Protection Bureau
To learn more about factors to consider when applying
visit the web site of the Consumer Financial Protection
http://www.consumerfinance.gov/learnmore.
Fees
Annual Fee
for or using a credit card,
Bureau at
Visa" Gold
Gold Masteroard"
None
None
Transaction Fees
• Balance Transfer
None
• Cash Advances
2.0% of the amount advanced ($2.00 min .. $10.00 max.)
• Foreign Transaction
None
Penalty Fees
• Late Payment
Up to $15.00
• Over-the-Credit-Limit
Up to $15.00
• Returned Payment
Up to $15.00
Other Fees
Telephone Payments $10.00
How We Will Calculate Your Balance: We use a method called "average daily balance" (including new purchases): An explanation of this method is provided in your account agreement.
Billing Rights: Information on your rights to dispute transactions and how to exercise those rights is provided in your account agreement.
SUMMARY
Will receive
INFORMATION
your certificates
state
your
IMPORTANT
Read
you
may
creou.
obtain
ttus
of
cernncetes
not need
upon
master
poliCY
66
at age
account
will
wm
ccounue
until
&
$10.000.
PA: ••••.••
r
to
OF
ABSENCE
Creditor
a
after
scheduled
on the
date
If you
pay
&
MO
maximum,
In a nenseescrel
acts.
life
Of
LEAVE
family
viclancn
off, you
In GA and
self-inflicted
residence
in MA.
of disability
return
your
tn
monthly
lhe
$10.000
the first
In
master
not
normal
GENERAL
COST
in NC;
23.9¢
8Q,1f;
in UT;
inTX;
rate
Honda
in your
disabllltv.
ct
only
and
age
Benefits
CO.
In all states
have
767¢
in AL;
in MO;
with
paid
payment
coverage
off, you
are
to
your
age if employed
NH, t'N,
NO.
except
65
In all states
days
In AL
TX &
PA.
in CO.
at age
71,
full-time.
of coverage
of pendtng
an immediate
of
01 a foster
rnmsnum
scheduled
to work,
or you
leach
are
retroecnve
10 a non-seasonal
occupation
of leave
and
(except
GA. IA. MA.&
8. TX;
MO
KS.
in
SD; 9 months
&.
MD
in OR
QRt
to
The
18 months
VA.
1A, MA
& PA;
66
except
in CO.
69 in AL.
MA & PA;
AZ.
914¢
in AR;
&. SD; 71 in
72 In NM.
GA
70 in AZ.;
in CA: 40.1¢
in CO; 83.80: in CT; 85.7~ in DC;
676~ in IN; 85.6~ in KS; 96M in LA; 65.5¢ in ME;
NH; 70.4¢ in NJ: 66.7¢ in NM; 29.2\!,: in NV; 53.1 e
PA; 75.8¢ in RI; 80.7¢ in SC: 82¢ in SO; 88.20: in TN; 19¢
66¢ inWY. The cost of credit insurance
will be financed
600: in A2:
in IA; 82.9¢
in MS:
e
81
Company
of absence
are
AR8801
ccmceov
provided
for the
If you
cancel
you
under
In
fmancial
SD,
numbers
days
ItS
conees.
receivtng
your
01
of
to file
us.
through
Fndav. except for federal holidays. Written
P.O. Box 977122. MiamI. FL 33197-7122
at
certiiicate,
ilnd
will
in the
other
of
CO,
CT,
for
life.
AC3892ECU>AOS.
refund
number
your
rfus
of
e.m.
8:00
documents
CA,
coverage
certificate
sale
between
Company
In AR.
under
we
interest
'-800.859-0490
correspondence
Insurance
WV & WY.
IS provided
has a fmancial
toll-free,
Bankers
FL 33157-6596.
VT, WA.
AC3757EQ.0297,
unemployment
creducr
The
American
Miami.
UT. VA.
TN,
AC3755P0..Q897.
for
obligatIon
30
date.
(A8LACl.
ROOSl Dnve,
AI, SC.
coverage
contact
should
Quail
OR,
lorm
lX
within
pnntmq
of Florida
11222
OH. OK,
NC.
EO-029a
as of the
a claim,
(ARICI,
NM.
responsible
are accurate
in
premium.
insurance.
and
be
should
p.m.,
via U.S
8:00
sent
This insuranu
produGr is not a deposit nor is if insured sr gUlKlInrHd by the FDIC, Finarn:f.llnstitution.
or efT)' fefhral
Agency.
We may not condition
your extension 01 ~rt on eftlu-r: rcur purdr.se of #In ;n$Unrrn;" product ffflm
or our .Hiliates, your agreement not to oblJlin insursnc. from II" unMfiliated entity, or s prohibition on your obtaining
in5Ura~
from
an unaffiliakd entity;
GCJW'mmenr
us
AR, LA
OH,
ME.,
an application
CtlffilNt
DC
concernIng
and
Include
was
application
MO
person
to
who
01 claim
matenal
NA
provide
k.nowlngly
contalnrng
thereto,
penalties.
Imprtsonme-nt
Arty
and
any
with
this
or rrusleadlng
Intent
mateuaHy
a fraudulent
ocnce is not
commits
residents:
false
to defraud
false
any
to
lor
for the
IS a crime
whICh
an InSUler
company
conceals,
act,
to life and
Information
insurance
Informa\lonor
Insurance
applICable
the
or other
purpose
and may
person
fifes
of mis!eadu19,
subject
such
person
10
eecreoeet.
health
purpose
of defrauding
the
Insurer
or any
residentscivIl
NM
residents:
false
incomplete,
who
presents
an Insurer
Intent
to
or mIsleading
k.nOWlngly
false
WIth
may
oeny
Insurance
defraud
Information
or wlltlully
mformation
Injure,
If
beretus
present
IS guilty
a false
In an applicallon
deceive
or
any
false
of a felonv
or fraudulent
101 insurance
insurel
Information
of the
claim
for
IS gUIlty
of "
on an applicatIon
for
fIles
materially
01
a statement
related
claim
or an
Arnt
person
who
Includes
false
who
knowingly
or misleading
InformatIon
Any
residents:
Arry
of an Insurance
PA residents:
insurance
or
apphcatron tor
person
policy
Anv
concerning
person
In an
stetemem
any
who
fact
knowingly,
ccntemtnq
cersco
of
containing
thereto
with
and
mtent
with
any
commits
or fraudulent
cnme
of a
incomplete
knowinglv
claim
a false
is guilty
and
any false,
who
material
presents
insurance
to Injure.
materially
false
SUbject
cnme
of a loss
an
may
Insurance
any
any
is gUilty
insurance
mtormaucn or
eel, which
of a loss
to CIVil fines
or deceive
information
to defraud
a fraudulent
tor peymenl
be
may
def/aud
or mlstead1f19
intent
claim
and
or
benefit
be subject
to
or
who
tmes
and
policy
is subject
01 benefit
or knowltlgly
and criminal
any
makes
or other
for the
conceals
insurance
Insurer,
IS a crime
and
INSURANCE
You, your spouse and dependent children up
to age 19 (age 25 if a full-time student at any
institute of higher learning) are automatically
covered with common carrier travel accident
insurance every time you travel by air, bus,
train, ship, taxi, or any other common carrier
anywhere in the world when you charge your
entire fare to our card. This coverage is provided
to you at NO EXTRA COST.
person
presents
penalties.
claim
for the
of
purpose
subjects
such
files
proceeds
an application
misleading,
person
CREDIT INSURANCE
10 criminal
of a felony
company
TRAVEL ACCIDENT
deqree.
thild
payment
penalties
Information
civil
and
pnscn.
In
and
ecctucn
In
knowingly
any false,
or wllHul1y
fines.
applicant
\Nho
person
Any
confinement
and/or
by the
person
containIng
residents:
knOWingly
OK
cnn-e
prOYlded
resieems:
NJ
a
civil
person.
eeoeinee
to a claim
Fl
is
It
Any
Of statement
any fact
SUbstantial
le5l0ems:
other
residents:
TN &VA
101"Insurance
Informanon
Visa®Gold or Gold
MasterCard® Credit Card
for the purchase of goods
or services, the following
benefits are yours!
creditor
Life Assurance
NH.
is solely
4S.6¢
in IL;
in MT; 20.5¢
"Your Independent Community Bank"
www.elkhornvalleybank.com
8. NE
plecemeru
your
off. you return
days
MA.
In ND
area;
Creditor
IS paid
MD,
or in wTltlng
or illness
disaster
30 consecutive
the urst 90
orally
to. accident
days
in PA. Unemployment
tV., CO,
tn
the $10,000
at least 30
or a controlling
30 consecutive
nOI available
15
to the
balance
after
covel
pay
reach
90 days
12 months
either
WOfk due
win
10 6 months
is 70.
hmited
notified
coverage
In
rmramcrn
for
after
master
errcatt
scheduled
contractor
begin
misconduct
beIng
the
a nonseasonal
or you
are employed
Benefits
Benents
TX
in
your
work.
to
reach
10
avalab!e
en independent
01 cnmlnal
from
Of you
on
In MA.
MA
In
in nonsdleduled
Creditor
return
if you
due
day of loss
full-Irme
flighl
15 not
P8V 10 the
employed.
& TX:
until
ttus
in ID; 73.7¢
$1.068
NE.
MO.
as a package.
Department.
Death
monthly
drsebted,
SO):
In a federally-declsred
during
or want
MOilday
Clctims
the
Bankers
and
Insurer
available
questions
Eastern TIme.
rreu tc. OFS
leave
will
benefIts
begin
FL. MO,
terminates
in HI; 86.4¢
53¢
Insurance
MS.
disclosures
cost
Accidental
if employed
&:
& PA. DisabIlity
Chargegard
leave
are Itmited
in CA.
Coverage
in AK:
in Mt;
Reliable
and
Each
are
Insurance
H you
65.7¢
AR8799E0-0298
AD9139CO-0499.
NAME
up to the
SD & TX
GA; 72.5¢
MI,
with
are no longer
Unemploymenl
reSiding
onlyl.
dale
tust.
of absence
enrollment
agreement
LA.
unemplO"/ment
AA8873PQ.019S.
Coverages
as of the
available
in 1X.
by American
10. IL. KS,
date
cerufcetes
WHOSE
retrcectwe 10 the first
IS not retroacuve
cccuceucn.
46.2¢ in NE; 71.8¢ in OH; 86.1 ¢ in OK: 68.9¢ ir, OR; 280: in
63.6e inVT; 26.1¢ inVA; 68.1(. inWI; 89\C inl/W; 75.4¢ inWA;
and American
GA.
When you use the ...
to
plmllflg
of death,
coverace
coverage
of absence
service:
& SD. you are ehglblefor
do not apply to leave
MA
is not
age
823¢
IS underWritten
DE. FL.
IS
for
set!
in NO;
(ABIC)
Insurance
insurance
dale
minimum
fOf cOllel/ilge
In CA
MD
8. lX.
leave
you
Chargegard
In MA.
MA
Im NC
duty
occurs
for Iwve
FL. lA, GA
in MA:
tn
military
jury
balance
payments
Maximum
In AL,
specified
Coverage
grand
whichever
coverage
59.S¢
36.4¢
and
as described,
the
PERSON
as of the
IS replaced
in AL, GA. IA. MD
pregnancy
01 duty
unperd
to active
or
payments
$100 PER MONTH:
in FL; 79.7~ m
PER
DE;
in MD:
recall
petit
GA. IA. MD.
enrollment
age
or neglect
an employer.approved
Benefit
PROVISIONS:
41.9¢
at the
In AL
benefits
No maximum
SSe in
take
maximum.
of Absence
No termination
you
coverage
risks
as ollhe
of the
TO THE
scheduled
and are
are ehglble
unemployed.
unemptoyment
on the outstanding
self-employed.
Leave
policies
seasonal
I adoption,
only): or
policy
of monthly
MD.
NM.
based
day of leave.
are
and
If you
NC
(In
payment
number
of estebhshed
childbIrth
home
enrollment,
vary by
same
to purchase
ere accurate
ONLY
Disability
to work,
SO. you
InJIJ'Y (except
irwoluntanly
your
account
1)(; normal
&
ABSENCE:
member;
child
of your
the
conditions
balance
coverage
payments.
whtchever
In MA
and
account
Creditor
days
monthly
IS paid
first
become
10 the
30 consecutive
for
payalle
or foreign
due on your
policy
unemployl"'r"lent
covers
required
disclosed
terms
APPLY
oUlstandlng
10 MD
will
minimum
of loss
occurs
are not
COVERAGE:
week
forbIdden
the
COVERAGES
the
except
Chargegard
begin
your
wntchevef
travel
pay
is excluded
Benefits
balance
01 fOte/gn
payment
master
hours
Rates
to modify
that
You are not
to change.
nght
as of the date of loss, until your balance
occurs
first. In MA & TX. you ere ellg!ble
cccuceucn tor the same employer.
and are not
stockholder
of your employer,
In IA & GA it employed
full-time
In a. ncnseescnet
01 unemployment
end are retrcecwe to the first day 01 loss. Unemployment
excludes discharge
for cause (except
In AL, AZ. CiA. IA. PA, SC & SO): wtltlul
monlhty
Insurance
regulations.
the
LEAVE
disabled,
Creditor
benefits
UNEMPLOYMENT
the
other
is optional.
In TX.
lotally
of loss
your
have
are subject
reserve
to state
will
Suicide
evarlsble
of $10.000.
Otsabthty
below
AND
Chargegard
become
pay to the
maximum
occupation.
MA
of
IS not
on the dale
Chalg8(Jard
pohcy
Life
rates
Premium
subject
If you
tnsurence
KY. MN & NY
IN:
die.
mtJximum
If you
ThiS credit
ACCOUNT.
If you
In IA
Dt5A~UTY:
your
AVAILABLE
for full detads.
insurance.
referenced
and
UNEMPLOYMENT
ONTHE
COVERAGE:
carefully
this
anytime.
nonce
wrinen
IS NOT
liFE. DISABIUTY,
APPEARS FIRST
liFE
10 cancel
The underwriters
ccncree
COVERAGE
policies
10 purchase
You ere free
disclosure.
andior
and/or
or want
OF INSURANCE COVERAGES
ON CHARGEGARD UMITA1l0NS,
EXCLUSIONS, COSTS: Upon acceptance
policies indicating
your ettectve dale, Eligibl!lty, restrictions
and exclusions
and/or
for
Our Credit Insurance program can protect your
card, your family, and your credit rating when
you may need it most due to unexpected events.
information
to criminal
bnd
penalties.
RI residents:
Any person
who knowingly
presents
a false or fraudulent
claim tor payment
of a loss or benefit
or krowinclv presents false
intcrmeticn in an application
for insurance
is guilty
of a crime and may be subjectto fines and confinement
in prison
WA residams: It is a crime to knowingly
provide
false.
incomplete.
or misleading
iofcrmation to an insurance
company for the purpose
of defrauding
the company.
Penalties
include
nronsonment
fines,
and denial of insurance
benefits
With Visa® Gold you also get ...
Og/13
CREDIT
INSURANCE
This following
PRE-PURCHASE
disclosure
is required
CREDIT
LIFE INSURANCE:
0101pay .•• hlo banal"
tn lho
CREDIT
injury.
30
age
as of the
flight
GENERAL:
pettod.
may
purchase
MA
RESIDENT
ONLY
optional
credit
hfe insurance
If you die while
coverage
is in force. we Will pay the
2 yo",,. if you di", """
,esult of SUIcide
01 your
in nonscheduled
di1l'( watllfl9
cntere
date
-APPLIESTO
law. You
outstanding
and
balance
credit
disability
of your
90-DAY PRODUCT PROTECTION
insurance
loan to the
creditor.
We
WIll
1"$01
COoJERAGE:
DISABILITY
payment.
DISCLOSURE
by MA
If you
become
disability,
aircraft,
to the
foreign
You eee elig.ble
for
disabled
creditor.
travel
this
while
We
01 foreign
covereq •• rf you
this
coverage
Will not
pay
reSidence
work
30
is
In force,
benefits
You
hours
we
If your
must
a week,
send
will
disability
proof
pay
up
is the
of disabitity
••re In a non-seasonal
to your
result
_ithin
minimum
of war,
a
monthly
seu-mtncteo
90 days. There
occupation
and
meet
IS a
the
below.
See
ceruncete
of
msurence
for
specific
deunmone.
You are
eligible
for
optional
croon
life
mswence
and
credrt
disability
Insurance
if you are between
18 and 65 years of age. Coverage
\/YIU expire
on your 66th binhday.
The maximum
benefit
IS $10,000.
You
may cancel this coverage at aroy nrne At[ unearned c-e-oums WIt! be c-eo-eo to you~ account by the acfuere! rnetl-cd for hfe coverage
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Covers new consumers product purchased in full
with our credit card against direct physica//oss
or damage for 90-days from date of purchase
(some exclusions apply.) Coverage is in excess of
other collectables insurance.