Georgia State University Federal Credit Union APPLICATION FOR ATM/DEBT CARD I'd like to apply for the following card(s):   ATM Card   Debit/Check Card VIEW ATM CARD AGREEMENT DEPOSITOR Credit Union Account No. ______________________________________________________________________________________________ First Name Middle Last ______________________________________________________________________________________________ Street Address City State Zip Code ______________________________________________________________________________________________ Previous Address (if less than three years at present address) ______________________________________________________________________________________________ Date of Birth Social Security No. Mother's Maiden Name ______________________________________________________________________________________________ DEPOSITOR 'S EMPLOYER Employer How Long? ______________________________________________________________________________________________ Address ______________________________________________________________________________________________ Street Address City State Zip Code ______________________________________________________________________________________________ Position-Job Title Annual Income Telephone Number ______________________________________________________________________________________________ * NOTICE: You need not list income from alimony, child support or separate maintenance if you do not want it considered.

JOINT DEPOSITOR Credit Union Account No. ______________________________________________________________________________________________ First Name Middle Last ______________________________________________________________________________________________ Street Address (IF DIFFERENT FROM DEPOSITORS) City State Zip Code ______________________________________________________________________________________________ Date of Birth Social Security No. Mother's Maiden Name ______________________________________________________________________________________________ JOINT DEPOSITOR 'S EMPLOYER Employer How Long? ______________________________________________________________________________________________ Address ______________________________________________________________________________________________ Street Address City State Zip Code ______________________________________________________________________________________________ Position-Job Title Annual Income Telephone Number ______________________________________________________________________________________________

SIGNATURE(S) By signing below, the undersigned request(s) the described services and agrees to the terms and conditions governing the services, including any fees and charges. The undersigned agree(s) that all information is accurate and authorizes the financial institution to verify credit and employment history by any necessary means, including preparation of a credit report by a credit reporting agency. X___________________________________________ X_____________________________________________ Signature of Depositor.           Date Signatureof Joint Depostior         Date

CURRENT DEBTS (Please attach another sheet if additional space is needed) (check one or both) Creditor Mailing address Present Balace Monthly Payments Depositor Joint Dep. (1)           (2)           (3)           (4)

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