Credit Card Acceptance Form
Seal and post or fax completed Request Form to
FOR OFFICE USE ONLY
1300 301 304 (24 hrs).
F O R FA S T A P P R OVA L , P L E A S E C O M P L E T E A L L S E C T I O N S O F T H I S F O R M A N D P R I N T I N C L E A R C A P I TA L L E T T E R S .
1. FIRST STEPS
a) Before you complete this Acceptance Form, please be sure you can say “Yes” to the initial approval criteria: Are you at least 18 years of age? Do you have a good credit rating? Are you a permanent Australian resident? b) YES! I want to apply for a: Silver MyCard Standard Rewards [SB] Gold MyCard Standard Rewards [GB] Gold MyCard BlueSky Rewards [GP] c) My Credit Union details:
Credit Union Name:
(Mandatory)
Agent Code:
SOURCE CODE:
( Check one box)
1
4
6
0 1
0
1
(Tick one box and complete the last digit, depending on your Credit Union)
Silver/Gold Standard Rewards Gold BlueSky Rewards
9WXY46Y3 7WXY46Y3
(Income $20,000 p.a. or over required) (Income $35,000 p.a. or over required) (Income $35,000 p.a. or over required)
5. YOUR MONTHLY FINANCIAL POSITION
This information will be used to determine your ability to make repayments on this credit facility. 1. Show your Total Monthly Income (after tax)
Exclude selected Government bene ts as source of income (apart from age and war pensions)
$
University Credit Society (Unicredit)
Credit Union BSB Number: Credit Union Member Number:
8
0
6
–
0
3 6
2. Show your Total Monthly Personal Expenses including:
• rent/mortgage • loan repayments (car, boat, credit cards, etc.) • living expenses (food, electricity, phone, gas, water, etc.) • insurance (life, health, car, etc.) • rates/body corporate • any other nancial commitments
– $
2. PLEASE TELL US ABOUT YOURSELF
Title Middle initial First name Surname
3. Calculate your Monthly Net Disposable Income by subtracting (2) from (1)
= $
6. PROFESSIONAL DETAILS
Residential Address (PO Box not acceptable) Number Street S uburb/Town Home telephone number S ta te P os tc ode Are you self-employed? Yes No Employer’s Name or Company’s trading name if self-employed Employer/Self employed trading address Number Street S uburb/Town Work telephone number S ta te P os tc ode
Mobile telephone no. (if any)
(
)
I consent to being kept informed about products, services and o ers via email and/or SMS.
Email address (if any) Date of birth (dd/mm/yyyy) Drivers licence number
(
Years:
)
Time with previous employer
Years: Months: Months:
Time with current employer Gross Annual Salary
/
/
Mother’s maiden name Are you (please tick) Married Single Divorced/Separate Widowed De facto Your spouse’s name No. of dependants (including self) Do you (please tick) Own home Rent
yy/mm
Other income
$
$
If income is earned from sources other than salary , please attach evidence to support the minimum income requirement of $20,000 p.a. for Silver or $35,000 p.a. for Gold (e.g. current tax return, bank statement, dividend certi cate etc. ). Exclude selected Government bene ts as source of income (apart from age and war pensions).
O c c upa tion
C ode: ( Interna l U s e O nly)
Mortgage
Board
yy/mm
I authorise my accountant to verify my details (Mandatory if self-employed):
Years at current residential address
/
Years at previous address
/
Name of external Accountant (if applicable) Accountant’s Trading Name Accountant’s address Number Street
Name of nearest relative/friend in Australia not living with you Residential address of relative/friend Number Street S uburb/Town S ta te P os tc ode
S uburb/Town Accountant’s telephone number
S ta te Accountant’s fax number
P os tc ode
Telephone number of relative/friend
(
)
(
)
(
)
3. ABOUT YOUR ACCOUNTS
Type of existing credit card(s) that you hold e.g. Visa, Mastercard, American Express etc
7. PLEASE SIGN HERE
I hereby apply to become a Credit Card customer. I have read the privacy declaration (on the back of this form) and I agree to its Terms and Conditions. I have also read the balance transfer declaration overleaf and authorise Card Services to process the balance transfer(s). I understand that for every $1,000 of credit that I use, a minimum repayment of approximately $30 is required each month.
Do you currently have any Credit Union savings or loan accounts? Yes No Client number
S igna ture
D a te
4. PRIVACY PREFERENCE
We may keep you informed about other products, services and special o ers from Citigroup companies and selected third parties that may be of interest to you. However if you do not wish us to communicate these other o ers to you, please indicate below: Do not mail Do not phone
/
/
If I have applied for a Gold Card, after processing this request, Citibank may instead o er me a Silver Card Account. I understand that my signature above constitutes my request for a Silver Card Account. For faster card approval, include a recent pay slip, tax assessment or group certi cate with your application.
FAX THIS END FIRST TO 1300 301 304
8. YOUR ADDITIONAL CARD (OPTIONAL)
I confirm the identity of and wish to apply for an Additional Card in the name of: First name Middle initial Surname
Additional Cardholder must be at least 16 years of age. The Primary Cardholder is responsible for all debts incurred by the Additional Cardholder. The card may be cancelled at any time by phoning Card Services. This may not be effective until the Additional Card has been surrendered or the Primary Cardholder has taken all reasonable steps to have the Additional Card returned to Card Services.
Additional Cardholder’s date of birth (must be at least 16 years old) (dd/mm/yyyy)
/
/
Signature of Additional Cardholder
✘
9. CREDITSHIELD® INSURANCE PROTECTION (OPTIONAL)
Yes, I would like to receive further information and an application form for CREDITSHIELD.® A Product Disclosure Statement is available and will be sent to you by Citicorp Life Insurance Limited ABN 75 004 274 882 AFSL 238096, the issuer of CREDITSHIELD® to determine whether it is appropriate for you. CREDITSHIELD® is designed to take care of your Credit Union Mastercard repayments when you can’t. CREDITSHIELD® will pay your minimum monthly payment until you are fit to return to work should you become temporarily disabled or for up to six months if you become unemployed. In the event of your death or total disablement, CREDITSHIELD® will pay the amount of your indebtedness to a maximum of $20,000. It costs just 45 cents for every $100 owing on your Card each month. Insurance is subject to policy terms and does not apply to Additional Cardholders.
10. BALANCE TRANSFER AUTHORISATION
Accounts to be transferred. I authorise Citibank Pty Limited (ABN 88 004 325 080) to transfer the following amounts from my nominated account to my Credit Card Account in
accordance with the Declaration (above) and the Balance Transfer Terms and Conditions.
Account name
(e.g. Mrs A.B. Smith)
Type of card/account
(e.g. Telstra Visa Card)
Amount to be transferred
Card/Account number
($ value must be specified – minimum $500)
1. Name and address of issuing organisation 2. Name and address of issuing organisation
TLP69N1
$ $ $
TOTAL AMOUNT TO BE TRANSFERRED
11. PRIVACY DECLARATION
I, the Applicant, by signing above specifically Agree and Acknowledge with, the card issuer Citibank Pty Limited ABN 88 004 325 080 AFSL No. 238098 (“Citibank”) as follows: 1. That Citibank hereby informs me that it may disclose to a credit reporting agency certain personal information about me including: information contained in this application; my identification; the amount of credit applied for; payments which may become more than 60 days overdue; advice that payments are no longer overdue; a serious credit infringement which Citibank believes I have committed; and the discharge of my credit card facility (if granted under this application). 2. That Citibank, in assessing this application and any later request for a credit limit increase, may obtain from a credit reporting agency a credit report containing personal credit information about me and, a credit report containing information about my commercial activities or commercial credit worthiness. 3. That Citibank may give to and obtain from any credit provider(s) that may be named in a credit report held by a credit reporting agency information about my personal or commercial credit arrangements including information about my credit worthiness, credit standing, credit history or credit capacity for the particular purposes for which the information is required. 4. That Citibank may give: (i) to any other bank, a banker’s opinion about my consumer credit worthiness for the purposes connected with my business, trade or profession; (ii) a credit report about me to any tribunal or the Banking Ombudsman or an authorised person, including my agent, accountant or solicitor; (iii) personal credit worthiness information to any entity participating in a credit card loan securitisation programme for the purpose of such a programme. 5. If Citibank approves my application for credit my above Consent and Acknowledgment will remain in force until the full amount owing to Citibank under my credit card facility is repaid and my account is closed. 6. That Citibank may disclose to any Additional Cardholder, information reasonably required to transact on the credit facility. 7. That Citibank may provide my personal and credit information to related companies in or outside Australia or selected third parties on a confidential basis for the purposes of providing administration, sales, marketing or other services in respect of my account or to determine whether I am eligible to receive any benefits relating to my account. 8. That Citibank and my Credit Union may disclose information to each other regarding my application and the conduct of my account for marketing and administrative purposes. 9. I understand that I will be automatically enrolled in the free Rewards Programme. I authorise Citibank for the purpose of the Rewards Programme to disclose my personal and transaction information to such persons or entity conducting the Rewards Programme for the purpose of conducting the Rewards Programme and to Qantas Airways Limited for the purpose of awarding Qantas Frequent Flyer points. 10. That Citibank will sometimes send me mail relating to this product (including newsletters, statements or offers to upgrade the services provided). If I do not wish to receive information on other products, services and special offers from Citigroup companies and selected third parties, I will notify Citibank in writing or by telephone or tick the Privacy Preference opt out box on this application. 11. Where you are not already a customer of one or more of the Citigroup companies, we have obtained your address for the purpose of making this offer to you. We disclose this information to our mailing house in order to determine whether you are an existing customer and whether you have previously indicated a preference not to receive this kind of material. If you decide to accept this offer, our future relationship will be governed by the privacy provisions that apply to the product.
OFFICE USE ONLY
12. BALANCE TRANSFER DECLARATION
I authorise Citibank to process this request. I confirm that I have read and agreed to the Balance Transfer Terms and Conditions enclosed. I acknowledge and agree that the Balance Transfer authorisation is a request by me for Citibank to advance funds; and the value of all Balance Transfers is a debt due and payable by me to Citibank.
Once this Application is completed, fax to 1300 301 304 (24 hrs), or alternatively, if you do not have a fax please mail to Card Services, GPO Box 1625, Sydney NSW 2001. Please note that approval is subject to Citibank’s credit criteria, and subject to your acceptance you will be billed at a later date an annual account fee of $35 for the Silver Card (Additional Cards are free). For the Gold Card with Standard Rewards, the annual account fee is $75 and for the Gold Card with BlueSky Rewards the annual account fee is $99 (Additional Cards are free). Allow up to 15 working days to process your Application subject to verification. Citibank Pty Limited ABN 88 004 325 080 AFSL 238 098 is the issuer and administrator of the Credit Union MasterCard. Citibank may check employment details/income with your employer or accountant named above. Income of $35,000 p.a. required for the Gold Card. Upon approval of your Credit Card we will notify you of how to meet the "100 Point Identification Check" as required by Federal legislation. CULCOI1244C
FAX THIS END FIRST TO 1300 301 304