EFTA00186420

# Account Application: Platinum MasterCard or Visa Platinum Credit Card

## A ACCOUNT INFORMATION

**YOU WISH TO OPEN THE FOLLOWING ACCOUNT:**

- **Platinum MasterCard (MR2/PLAT)**
- **Visa Platinum Card (MR3/PLAT)**

**YES, Please sign up for Chase Travel Rewards**

---

### A ACCOUNT INFORMATION

| Accountholder Name | Date of Birth | Social Security Number |
| :--- | :--- | :--- |
| Mailing Address | 301 East 66th Street, Apt 10N | City New York | State NY | Zip Code 10021 |
| Length of Time at Current Address | 01/01/04 | Rent |
| Number of Dependents (including yourself) | | Mother's Midden Name (Required for Security purposes) |
| Previous Home Address (If current address less than three years) | | City State | Zip Code |
| Years There | 10 | | |
| Name of Business | Business Telephone Number | Yeast There |
| Business Address | City State | Zip Code |
| Status | Self Employed Retired |

### B ADDITIONAL CARDS FOR AUTHORIZED USERS

**PLEASE ENTER CARDS FOR THE PERSONS LISTED BELOW (FIRST, MIDDLE, LAST):**

- FED 24 2004
- PRIORITY SERVICES

### C FINANCIAL INFORMATION

**PLEASE COMPLETE THIS SECTION WITH TOTALS FOR ALL APPLICANTS OR ATTACH A CURRENT FINANCIAL STATEMENT:**

- **ANNUAL INCOME**
- Account Holder

*All attorneys, valid impost, or requires maintenance must not be revoked for noncompliance as a basis of repaying a loan extended under a law of credit.*

### D AUTOMATIC PAYMENT

**PLEASE SELECT ONE IF YOU REQUEST AUTOMATIC BILL PAYMENT FROM YOUR ACCOUNT:**

- Minimum Payment. The minimum balance due will be paid on your card automatically each month.
- Full Payment. The full balance due on your credit card will be paid automatically each month.

**PLEASE BRIT THE FOLLOWING ACCOUNT FOR PAYMENT ON THE BALANCE:**

- Bank Name: J.P. Morgan Chase
- Account #:

### E SIGNATURE

**I HAVE READ AND AGREE TO THE NOTICE AND ADDITIONAL DISCLOSURES ON THE REVENUE**

- Signature (Primary Account Holder) Date:

### INTERNAL USE ONLY

- CA Plag 6 Location Code 211211 Credit Line AUM
- Number Client Service Terms CST #
- ACT # ACT 4

See here 2 for Disclosures regarding rates, fees, and additional costs and other information for this offer.

21500

EFTA00186421

| 2 TO 97584078 | P.08/09 |

| :--- | :--- |

## Account Application: Platinum MasterCard or Visa Platinum Credit Card

### A ACCOUNT INFORMATION

YOU WISH TO OPEN THE POLLOWING ACCOUNT:

- Platinum MasterCard (MR2/MPLAT)
- Visa Platinum Card (MR3/VPLAT)

Yes, please sign up for Chase Travel Rewards.

| Accountholder Name | Date of Birth | Social Security Number |
| :--- | :--- | :--- |
| Mailing Address | City | New York | State | NY | 10021 |
| Telephone Number | Length of Time at Current Address | Rent | Mother's Maiden Name | Required for Security purposes |
| Previous Home Address (if at current address less than three years) | City | State | Zip Code | |
| Years There | 10 | | | | |
| Name of Business | Business Telephone Number | Years There | | |
| Business Address | City | State | Zip Code | |

**B ADDITIONAL CARDS FOR AUTHORIZED USERS**

PLEASE ISSUE CARDS FOR THE PURCHASES LASTED BELOW (FIRST, MIDDLE, LAST).

FED-2-4-2004

**C FINANCIAL INFORMATION**

PLEASE COMPLETE THIS SECTION WITH TOTALS FOR ALL APPLICANTS OR ATTACH A CURRENT FINANCIAL STATEMENT:

- ANNUAL INCOME*
- Accountholder $

*All payments, child support, or separate maintenance need not be rewritten for consideration as a basis of repaying a loan extended under a line of credit*

**D AUTOMATIC PAYMENT**

PLEASE SELECT ONE IF YOU REQUEST AUTOMATIC BILL PAYMENT FROM YOUR ACCOUNT:

- Minimum Payment. The minimum balance due will be paid on your card automatically each month.
- Full Payment. The full balance due on your credit card will be paid automatically each month.

PLEASE DEBIT THE FOLLOWING ACCOUNT FOR PAYMENT ON THE BALANCE:

Bank Name | Bank Number | Account #

**E SIGNATURE**

I HAVE READ AND AGREE TO THE NOTICE AND ADDITIONAL DISCLOSURES ON THE REVERSE

SIGNATURE (Primary Accountholder) | Date |

**INTERNAL USE ONLY**

CIA Flag | 6 Location Code | Credit Line | AUM |
Basket | Client Service Team | 657# |
ACT Date | ACT # |

See page 2 for Disclosures regarding fees, fees and additional costs and other information for this offer.

2,500 Susan