select one: QI Citibank MasterCard® or QI Citibank Visa®
Please use ballpoint pen.
Print full name First Middle Initial Last Name ot School I I I I I I I ( IBac
as you wish it to (do not abbreviate) II I I I I Bac
appear on card Your Address at School
Social ( I I I IDate of Moi Da y Yr Number and Street I I I I ( I
Security Number I Birth (ifldifferenttfrom permanent address) I I 1 1 1
Permanent I( (I I I I I I I I I I I City. TOnic I I (I(( I I I State' i p d
City, Town it I II I IIIState ~ Zip I Your Phone Number and ( I Address to Snd Card&aBillin
or Pst Office I I I' I I I I I I I I Code I Area Cde at School / j j Statement II Permanent L. School
Permanent Phonerea Cdene Name That
an Are Cod iI I I I Appears on Phone Bill I I f ( ' I I ( I ( ( I ' l
Name That I I I I I I I I I I I I Your class Ql Freshman E1 Sophomore
Apears on Phone Billj Q I I I I Junior Q Senior Q Graduate Student Q Faculty/Stall Q Other ________
U.S. Citizen? QYes It No, Are You QYes Major El Full-Time Student
El No A Permanent Resident? El No PatTmSudn
Annual QSource(s): El Allowance/Savings El Summer Job Please include a copy of one ot the followng so that your application can be processed Immediately.
Income' r' El Salary/Stipend El Paid tuition bill for current semester Li Validated Student ID with Current Enrollment Sticker
Name of Employer (Present. "
Future or Previous/Summer) .- 7 W M ~ - lid!
Employer Telephone By signing below I authorize Citibank (South Dakota), N.A. to check my credit history and eachange
I i information about howlI handle my account with proper persons and with credit bureaus it l am issued a
and Area Code 5 / I I I I I ( card. I authorize my emptoyer, my bank. and any other references listed above to release and/or verity
MnyMreAconNubrBank Name information to Citibank (South Dakota), N.A. and its affiliates in order to determine my eligibility for the
MnyMaktAcutNme Citibank credit card. l am aware that information gathered about me is used to determine my eligibility tor
(Joint or Individual) the credit card account and any renewal or future extension of credit. IllI ask. I wilt be told whether or not
consumer reports on me were requested and the names of the credit bureaus, with their addresses, that
Savings Account Number Bank Name provided the reports. IllI permit my spouse lo use my card, I understand that account information wilt also
(Joint or Individual) be reported to credit bureaus in my spouse's name. I certify that l am 1B years of age, or older, and that the
information provided is accurate. I understand that it I use the card or authorize its use or do not cancel
Checking Account Number Bank Name my account within 30 days alter I receive the card, the Citibank Agreement sent to me with the card will
(Joint or Individual) be binding on me. Terms are subject to change.
'You need not include spouse's income, alimony, child support or separate maintenance payments paid In order to be considered tarea Citibank MasterCard orea CItibank VIsa card you must complete end
to you it you are not relying an them to establish creditworthiness sign this application. Omissions of any of the information requested In this appIcatlon may be grounds
tor denial. I verify that I have read end understand the disclosure boa on the bak. Please do not sand
payment of $20 annual tea; you will be billed later.
84 2 o Applicant's Signature Dt
E8442 - 11 Toensure that your application is processed as quickly as possible, please complete all
the information requested and mail to: Citibank (South Dakota) N.A., Citicorp Credit
Services, Inc. (MD), One Citicorp Drive, Hagerstown, Maryland 21748-0002.