1st Farm Credit Services Access Card Application
Cardholder
______- -
First Name Middle Initial Last Name Social Security Number
______
Street Address City State Zip
______
Mailing Address City State Zip
______
Date of Birth (mm/dd/yy) Drivers License No. State Expiration Date (mm/dd/yy)
() ______
Phone Number Loan Number CIF Number
()______$______
Work Phone # Mother's Maiden Name Requested Card Limit
Additional Cardholder #1
______- -
First Name Middle Initial Last Name Social Security Number
______
Street Address City State Zip
______
Mailing Address City State Zip
______
Date of Birth (mm/dd/yy) Drivers License No. State Expiration Date (mm/dd/yy)
() ______
Phone Number Loan Number CIF Number
()______$______
Work Phone # Mother's Maiden Name Requested Card Limit
Additional Cardholder #2
______- -
First Name Middle Initial Last Name Social Security Number
______
Street Address City State Zip
______
Mailing Address City State Zip
______
Date of Birth (mm/dd/yy) Drivers License No. State Expiration Date (mm/dd/yy)
() ______
Phone Number Loan Number CIF Number
()______$______
Work Phone # Mother's Maiden Name Requested Card Limit
Additional Cardholder #3
______- -
First Name Middle Initial Last Name Social Security Number
______
Street Address City State Zip
______
Mailing Address City State Zip
______
Date of Birth (mm/dd/yy) Drivers License No. State Expiration Date (mm/dd/yy)
() ______
Phone Number Loan Number CIF Number
()______$______
Work Phone # Mother's Maiden Name Requested Card Limit
Additional Cardholder #4
______- -
First Name Middle Initial Last Name Social Security Number
______
Street Address City State Zip
______
Mailing Address City State Zip
______
Date of Birth (mm/dd/yy) Drivers License No. State Expiration Date (mm/dd/yy)
() ______
Phone Number Loan Number CIF Number
()______$______
Work Phone # Mother's Maiden Name Requested Card Limit
By signing below, the Borrower hereby requests that the Lender issue an Access Card (a “Card”) to each of the Cardholders listed above in accordance with the terms of the Access Card Agreement (the “Agreement”) entered into by and between the Borrower and the Lender in connection with the loan that is identified on the Lender’s books as loan no. ______(the “Loan”). The Borrower hereby represents and warrants to the Lender that the information above is true, correct, and complete to the best of his, her or its knowledge. The Borrower further agrees that any Purchase (as that term is defined in the Agreement) which is made using any Card issued to any Cardholder will be added to the balance of the Loan in accordance with the terms of the Agreement. The individual signing below on behalf of the Borrower hereby represents and warrants to the Lender that he or she has been duly authorized to sign this application on behalf of the Borrower.
By signing below, each Cardholder represents and warrants to the Lender that (a) he or she has received a copy of the Agreement from the Borrower; (b) he or she will use the Card only for business or agricultural purposes and in accordance with the terms of the Agreement (which is hereby incorporated by reference); and (c) the information above is true, correct and complete in every respect.
BORROWER:
By: ______
Name: ______
Title: ______
CARDHOLDERS:
______
Signature Date Signature Date
______
Signature Date Signature Date
______
Signature Date