MasterCard® Application

To apply please complete the following information, print and mail the form below to: CVNetCenter™ Cumberland Valley National Bank PO Box 709 London, KY 40743-0709 Attn: Automated Services Or leave the form with a customer service representative at any CVNB location. We cannot accept enrollment via e-mail or fax because we require original signature(s) on the application form. Please complete all portions of the application to avoid delays in processing.

Platinum Card Gold Card Classic Card Applicant Information First Name Middle Initial Last Name Birthdate Number of Dependents Current Address City State Zip Do you? Rent Own Live with Parents Monthly Rent/Mortgage Time at Current Address Home Phone Social Security Number Previous Home Address (if current address is less than one year) City State Zip Time at Address Employer Occupation Gross Income Employer Address Business Phone Station No Badge No Length of Employment Previous Employer (if current is less than one year) Occupation Address Length of Employment   Credit Reference 1 Name Address Balance Due Monthly Payment Credit Reference 2 Name Address Balance Due Monthly Payment Credit Reference 3 Name Address Balance Due Monthly Payment Credit Reference 4 Name Address Balance Due Monthly Payment     Checking Account with Account Number Savings Account with Account Number Auto Financed By Make & Year Presently have cards with Other Income - Source* Name of Relative not living with you Address City State Zip Relationship to You If you and another person wish to have a joint MasterCard account (that is, you will both use or be contractually liable upon the same account) please provide us with the following information, and ask him or her to sign below next to your signature Co-Applicant First Name Middle Initial Last Name Co-Applicant's Current Address City State Zip CO-Applicant's Social Security Number CO-Applicant's Employer Position/Title Employer Phone Length of Employment Net Income CO-Applicant's Previous Employer *Income from alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis of repaying this obligation Undersigned hereby authorizes you or any credit bureau or other investigative agency employed by you to investigate any reference given by undersigned or statement or other data obtained from undersigned or from any other person pertaining to undersigned's credit and responsibility. Undersigned also authorizes you to furnish to other persons, upon request, information concerning undersigned's credit and financial transactions or experiences with the bank. 2 Signatures Required for 2 Cards to be Issued     Applicant Signature: _____________________________________ Date of Application: _____________________________________     Co-Applicant Signature  (if joint credit sought): _____________________________________ Date of Application: _____________________________________     Requested Credit Line Amount                  For Bank Information Only:  Agent        CL       EXP             No. of Cards   Date            CYC