Balance Transfer Form

Fields marked with * are required.

Member Information

• Member Name *
• Member Number *
• VISA Account Number *
• Expiration Date *

Account #1

• Card Issuer *
• Exact Amount *
• Card Issuer Payment Address *
• City *
• State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Zip *
• Account Number *

Account #2

• Card Issuer
• Exact Amount
• Card Issuer Payment Address
• City
• State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Zip
• Account Number

Account #3

• Card Issuer
• Exact Amount
• Card Issuer Payment Address
• City
• State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Zip
• Account Number

By submitting this form, you understand and agree to the Balance Transfer Fee, unless otherwise noted, which can be found in the Application and Solicitation Disclosure provided to you at the time of opening. You may request a copy of the Application and Solicitation Disclosure by calling 630-844-4950, visiting your local branch location, or visiting our website www.earthmovercu.com.

Please allow up to 2 weeks for processing.

**Continue to make your minimum monthly payment in order to avoid any late fees or additional charges.