Personal Credit Application Form
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1
2Personal Credit—Council Bluffs Savings Bank
Platinum
Cash
Platinum
*$19
Card
Rewards
Rewards*
Enrollment
Fee
01 PLAMA AGNT A0073 (Rew=N)
01 REWMA AGNT A0073
01 PLAMA AGNT A0073 (Rew=Y)
applicant information
1
“I”, “me”, “my” in this application means each applicant named above, and “you”
and “your” means Fifth Third Bank, an Ohio banking corporation that will review my
credit application in its Ohio offices and may extend credit to me from Ohio under
a Card Agreement accepted and made there. I certify that (a) I am at least 18 years
first name
initial
last name
of age, (b) I am either a citizen or permanent resident of the United States, (c) I read
and understood the terms and disclosures included with this application, including
arbitration, and have agreed to them, and (d) all of the information contained in this
social security #
date of birth
mother’s maiden name
application is true, accurate and complete. You may review and verify my credit,
income and employment histories and any other information needed to process this
own
$
yrs.
mos.
,
application, service my credit card account, manage your relationship with me and
rent
for any other legitimate business purpose. You may share with others, as permitted
mailing address
(cannot be a P.O. Box)
board
how long?
monthly payment
by law, such information and information about your credit experience with me.
I understand a negative credit report reflecting on my credit record with you may
city
state
zip
home phone #
be submitted to credit reporting agencies if I do not fulfill my credit obligations. I
agree that you may obtain a consumer credit report about me in connection with
processing this application, and later for account review or collection, credit line
increases and other legitimate purposes including updates, renewals or future
home address
city
state
zip
(if different from mailing address - cannot be a P.O. Box)
credit extensions. Upon my request, I understand you will inform me whether a
consumer credit report was obtained, and if it was, the name and address of the
agency furnishing the report. I understand the Privacy Policy I receive from you
employer
driver’s license
will describe how I may limit or authorize the way you share nonpublic personal
length of
information about me with affiliated and nonaffiliated parties.
$
employment
,
(in years)
If you approve this application and I or any Co-Applicant use the account, I
occupation
gross annual income**
business phone #
understand that (a) I will be bound by the terms of this application and the Card
Agreement in effect from time to time, (b) you may change the account and Card
Agreement terms from time to time in the manner permitted under applicable law
co-applicant information
and (c) I will be individually and jointly responsible with any Co-Applicant for what
(State of Wisconsin residents must provide spouse’s information)
is owed on the account even if only my Co-Applicant has used the account. If I have
2
completed the Balance Transfer request, I certify that I read and understood the
terms and disclosures applicable to balance transfers included in this application
and authorize you to complete my balance transfer request.
co-applicant name
date of birth
social security #
Customer Identification Program: In accordance with the USA PATRIOT Act,
federal law requires all financial institutions to obtain, verify, and record information
that identifies each individual or entity opening an account. This includes all
co-applicant mailing address
city
state
zip
(cannot be a P.O. Box)
personal and commercial accounts including loan and deposit accounts, as well as
trust, brokerage, insurance and investment management accounts.
home mailing address
city
state
zip
What This Means To Our Customers: When you open an account, you will be
(if different from mailing address - cannot be a P.O. Box)
asked for your name, address, social security or tax identification number, date of
birth (if applicable) and other information that will allow Fifth Third to identify you.
You will also be asked to furnish your driver’s license or other identifying documents.
mother’s maiden name
driver’s license
We are required to follow this procedure each time an account is opened, even if
length of
$
you are a current customer of Fifth Third. Thank you for helping us to follow this
employment
,
federally mandated procedure.
(in years)
employer
gross annual income**
business phone #
FOR INTERNAL USE ONLY
Once you receive your new card, call 1-877-881-6018 to transfer your
high-rate balances and take advantage of our Introductory 0% APR* offer.
referring employee number
3
*See Credit Card Disclosure for Intro APR details.
X
signature of applicant: ___________________________________________________________________________________ date: ________________________________
Cards are issued by Fifth Third Bank, Ohio pursuant to a license from MasterCard International.
signature of co-applicant: _________________________________________________________________________________ date: _______________________________
X
councilbluffs—cons04/08
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