Select One: Citibank Classic Q MasterCard® or D Visa®
To speed processing of your application, please complete all sections below. Write N/A for any items that do not apply to you.
10-90
Print full name First. Middle Initiai, Last Social Security Number
Permanent Home Address Apt. No. Cupy or Town Stain Zip
Your Mailing Address at School (if different from Permanent Address) Apt. No. City or Town Siuie Zip
YuAraCod and Phone Number at Schooi First/Last name under which phone is listed with Directory Assistance
YorClas Fresh I ] Junior [ J Grad (JOther Graduation Date Permanent US Resident Address to which you want your card and biiling statement maiied
(]Soph OSenior I I Faculty/Staff Li Yes Q] No Ui Permanent Ui School
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" aig con JYes Bank Name Acceptabie sources of income: Ui Allowance from Parents Ui Salary
JonorIdvdual) [ J No Yearly Income $ Li Savnogs Li Summer Job
'You do not have to include spouse's income, alimony, child support or separate maintenance
-payments paid if you are not relying on them to establish creditworthiness.
Checking Account [ J Yes Bank Name Financial aid and tuition are not applicable as sources of income.
(Joist or Indinidual) I I No Employer (Present, Future or Prenious/Summer)
Money Market (]IYes Bank NameEmlyrAecct
NOW Accounts No YeandpPhrnea umbe
Please include a legible copy of one of the following: Your application cannot be processed wihout tis information and will be substantially delayed if you
( VALIDATED Student I0 OR ( ] Tuition bill for omit any information requested. lBe sure the copy snows your name, the date and your current
for current semester current semester enrollment status Photocopy both sides it necessary)
prns afflriaes anit redi~tbureusi Iam isued acar I autirrma emlnn rnn r my bankand any or reerernces istedaboveio releaseand/nr atracherddislnosubx
very rnonatin Cibark (Sourh Dakota) N0 and its affiiaes in order to detrmr ine yiiiyr file Citibnk Classic credit carn ard ary future Inr der i be cosidered ora Gba Maturereo a CitiankV as card youm us oea l eer te and sign iris appilsation. Oihs ot any at tire
extensinsr ofcred~itI I ask, Iawll be tld wetrnnnror ntcnunr reporsannmn r requted and thenames ofth r reitbreaus. nrh r adrnsses. information rneuested inethsappicationmay be gerndstor deia. Iuerfitthati I he"readandr steaid thediscoure bonthebck. Please de
ertifyrrthaft a 8yars ofae.rldr, anrt h nforrmationrovids accurae. Iundrsandharrr sethercannrd nrah rieisuer dn o cancl
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I1CKNW 01001 06004 001A
Applicant's Signature bate
Applicant's Signature
Date