select one: Q Citibank MasterCard® or Q Citibank Visa®
Please use ballpoint pen.
Print full name First Middle Initial Last Name of School Branch
as you wish it to (do not abbreviate)
appear on card .Your Address at School
Social I Date of Mo Day Yr Number and Street
Security Number Birth (if different from permanent address)
Permanent I I City Town I I State( Zip
Address or Post Office I Code
City, Town State Zip Your Phone Number and Address to Send Card & Billng
or Post Office I IIIIIIIII Code' II I Area Code at School \ / I i l Statement l Permanent L] School
Permanent Phone Name That
and Area Code \ Appears on Phone Bill ( , ( l
Name That I ( I I I ( I ( Your class L Freshman L Sophomore
Appears on Phone Bill Junior L Senior L Graduate Student L Faculty/Staft Q Other
U.S. Citizen? Q Yes If No, Are You Q Yes Major L Full-Time Student
L No A Permanent Resident? L No L Part-Time Student
ADD.T5ONAL 7NF RMAT1ON VERIFCATION INFORMATION
Annual Source(s): Q Allowance/Savings L Summer Job Please include a copy of one of the following so that your application can be processed immediately.
Income' L Salary/Stipend Q Paid tuition bill for current semester L Validated Student ID with Current Enrollment Sticker
Name of Employer (Present.
Future or Previous/Summer) PLAS G A T R AIN
Employer Telephone / By signing below I authorize Citibank (South Dakota), NA. to check my credit history and exchange
and Area Code information about how I handle my account with proper persons and with credit bureaus it I am issued a
a A C o card. I authorize my employer, my bank, and any other references listed above to release and/or verity
Money Market Account Number Bank Name information to Citibank (South Dakota), N.A. and its affiliates in order to determine my eligibility for the
Citibank credit card. I am aware that information gathered about me is used to determine my eligibility for
(Joint or Individual) the credit card account and any renewal or future extension of credit If I ask, I will 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. If I permit my spouse to use my card, I understand that account information will also
(Joint or Individual) be reported to credit bureaus in my spouse's name. I certify that I am 18 years of age, or older, and that the
information provided is accurate. I understand that if I use the card or authorize its use or do not cancel
Checking Account Number Bank Name my account within 30 days after 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 for a Citibank MasterCard or a Citibank Visa card you must complete and
to you if you are not relying on them to establish creditworthiness. sign this application. Omissions of any of the information requested in this application may be grounds
for denial. I verity that I have read and understand the disclosure box on the back. Please do not send
payment of $20 annual fee; you will be billed later.
Applicant's Signature Date
E C541 112 To ensure 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.