Credit Card Application
A Subsidiary of Nebraska Furniture Mart, Inc.
(402) 397-6100 • 1-800-359-1200
Please fill out this form & sign agreement on the next page.
Mr.
First Name
Middle
Last Name
Social Security Number
Date of Birth
Mrs.
Ms.
Street Address
City
State Zip Code
Years at Residence Own
Home Phone
Rent
Other
Employer (IF SELF - Name of Business)
Job Title (Military - List Pay Grade)
Full Time Yearly Salary Years Employed Work Phone
Part Time
Nearest Relative (other than Joint Applicant) Street Address
City
State Zip Code
Phone
Section A - informAtion regArding PrimAry APPlicAnt
Mr.
First Name
Middle
Last Name
Social Security Number
Date of Birth
Mrs.
Ms.
Street Address
City
State Zip Code
Years at Residence Own
Home Phone
Rent
Other
Employer (IF SELF - Name of Business) Job Title (Military - List Pay Grade)
Full Time Yearly Salary Years Employed Work Phone
Part Time
Section B - informAtion regArding Joint APPlicAnt
Where do you bank?
Location
Mother’s Maiden Name (To help prevent unauthorized use)
Yes! I wish to enroll in Optional Payment Protection. I have read and agree to the cost, benefits and exclusions noted in this brochure.
I understand that enrollment is optional, I am free to cancel at any time and I can purchase property coverage from any insurer I choose.
Form J472
Initial Here to Enroll Date
Print Name of Cardholder to be Primary Insured Print Name of Cardholder to be Co-Insured Policy
Forms 10085
(either applicant may initial)
for Life and Family Leave Coverage
Rev 9/2009
Section e - PAyment Protection AuthorizAtion
Alimony Per Month
Child Support Per Month
Other - Please Specify
PrimArY APPliCAnt iD
Joint APPliCAnt iD
Drivers License State
Identification Number
Ex