Home Trust Secured VISA

Application for the Home Trust Secured VISA® Credit Card

please fill out and print the following form,
including your cheque or money order, and mail it to:

Home Trust Company
Attn: Secured VISA
145 King Street West, Suite 1910
Toronto, Ontario
M5H 1J8

PLEASE TELL US ABOUT YOURSELF

Social insurance number (mandatory**)

Title: Mr. Mrs. Ms. Miss Dr.

First name Initial
Last name

Date of birth (mm/dd/yy) / / Must be age of majority in your province.

Mother's maiden name

CURRENT ADDRESS

Street # Street name
Apartment #

City/Town Province
Postal code

# of years there: Months

Mobile phone Home phone

E-mail Address

MAILING ADDRESS (if different than above )

Street # Street name
Apartment #

City/Town Province
Postal code

PREVIOUS ADDRESS

Street # Street name
Apartment #

City/Town Province
Postal code Number of years there:

SOURCE OF INCOME

Monthly income (before tax) $

Source of income

Self employed: Yes No Student: Yes No

Current employer name (if employed)

Occupation

Business phone # # of years/months there

IF STUDENT PLEASE COMPLETE

Educational institution
Course of study
# of years completed

DO YOU REQUIRE A SECONDARY CARD? TELL US ABOUT THE CO-APPLICANT.

MAXIMUM OF TWO CARDS PER ACCOUNT CAN BE ISSUED.

First name Initial
Last name Date of birth (mm/dd/yy) / /

Home phone

Current employer name/source of income

Business phone

Social insurance number

† I certify the above information to be true and correct and by signing below accept as notice in writing of, and consent to, collection, use, disclosure and verification of any credit, personal or other information about me at any time from, to or with any credit reporting agency, credit grantor, or any other person with whom I may have financial dealings or as may be permitted or required by law. I authorize those parties to give information to you. I understand that all such information shall be collected, used and disclosed by you, and any affiliates, agents, service providers, successors or assigns thereof to assess my creditworthiness for this application and my on-going credit worthiness, for determining my eligibility for any other products and services to be offered to me and for such other uses not prohibited by law. By signing this application, I agree to abide and be bound by the terms and conditions of the Cardholder Agreement which Home Trust will send (as amended or restated from time to time). I agree that you may open a Home Trust VISA account in my name ("Account"), issue me card(s), Personal Identification Number and renewals or replacements from time to time. I agree if I use my card or Account, I shall be deemed to have requested and received the card, Account and Cardholder Agreement, and that I agree with everything written in the Cardholder Agreement and this application. Where a co-applicant signs this application, we acknowledge the terms of this application and all consents given in it bind both of us, and all references to "I" shall mean the applicant and co-applicant individually. Each applicant and coapplicant, shall be jointly and severally liable for any indebtedness incurred through the use of the cards issued pursuant to this application. I may obtain your privacy code or review my options for refusing or with drawing this consent, including my option not to be contacted about offers of products or services. My Security Deposit will be held in an interest bearing account with interest payable to me annually. Interest rates paid on the Security Deposit are shown on my Account Statement and are subject to change. I am required to make regular payments of 3% of the outstanding balance or $10 (whichever is greater) on my Account. Failure to do so will result in forfeiting the Security Deposit up to the amount of the Debt owing.

A monthly fee of $7.50 applies, plus $3 monthly for a co-applicant beginning with the second statement. If approved, your account will be charged a one-time set up fee of $39, which will be billed on your first statement. There is an over limit fee of $29 for every month the credit limit is exceeded and an NSF payment cheque fee of $39. Annual interest rate on unpaid balances is currently 19.50% for purchases and 21.50% for cash advances. For Accounts in Arrears the annual interest rate on unpaid balances is 24.50%. These rates and fees are subject to change with notice. Deposit minimum is $750. Deposit maximum is $10,000. ** My Social Insurance Number is required on this application for tax reporting purposes on the interest from my Security Deposit account.

Signature ___________________________ Date (mm/dd/yy) / /

Co-app Signature ________________________ Date (mm/dd/yy) / /

Cheque or money order amount $

Cheque or money order enclosed payable to Home Trust VISA^?

Western Union Money Control #

How did you hear about us?:

Home Trust website Broker Radio Newspaper Other:

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