Welcome to the SAM'S CLUB® Personal Credit Account Application

This form is designed to be printed and filled out by hand. To shorten response time, please answer all questions carefully and completely, sign and date the application, and bring the application to your local SAM'S CLUB for processing.

 Click here to find your local SAM'S CLUB.

1. APPLICANT: Please tell us about yourself.

SAM'S CLUB Member Number:

First Name :  

Middle Initial :  

Last Name :  

Home Address :  

Street Name & Number Required

City :  

State :  

ZIP Code :  

Home Phone :

Date of Birth :  

Social Security # : 

Alternate Phone :  

E-Mail Address:

By providing my e-mail address, I consent to receive e-mail communications about my account and authorize you to provide my e-mail address to SAM'S CLUB so I can receive special offers and updates.
2. AUTHORIZED BUYER: (Authorized Buyers MUST be active on membership)
An additional card will be issued to the person indicated below. The primary cardholder will be liable for all purchases made on the account, including those made by any authorized user.

First Name :  

Middle Initial :  

Last Name :  

Relationship to Applicant: 


Home Phone : 

Work Phone : 

Date of Birth :  

Social Security # : 

3. APPLICANT: We need your signature below.
By signing this application, I ask that Synchrony Bank ("you") issue me a SAM'S CLUB Personal credit card. I understand that if I qualify for a SAM'S CLUB credit card, you may open a SAM'S CLUB Premier Account or a SAM'S CLUB Standard Account depending upon my creditworthiness as determined by you. I am providing this information both to you and to SAM'S CLUB. I also authorize and direct you to furnish information about me (including whether this application is approved or declined) and, if it is approved, information about my Account, to SAM'S CLUB (and its affiliates) for use in connection with the SAM'S CLUB Credit Card program, including to create and update their customer records for me, to assist them in better serving me, and to provide me with notices of special promotions, catalogs and tailored offerings. I affirm that the information I have submitted is complete and truthful. I authorize you to make inquiries you consider necessary (including requesting reports from consumer reporting agencies and other sources) in evaluating my application, and subsequently, for purposes of reviewing, maintaining or collecting my account. I also understand that the SAM'S CLUB Personal credit card agreement (the "Agreement") attached to this application will govern my Account, the terms of which are hereby incorporated by reference into and made a part of this application, and that THE AGREEMENT'S TERMS INCLUDE AN ARBITRATION PROVISION WHICH MAY SUBSTANTIALLY LIMIT MY RIGHTS. My signature on this application represents my signature on the Agreement. I acknowledge that under the Agreement, I grant you a security interest in goods purchased on the Account, as permitted by law. I understand that there is no agreement between us until you approve my application. After credit approval and subject to the governing credit agreement, each Applicant may use this Account and will each be liable for all credit extended under this Account to any Applicant or Authorized User. I agree that my annual SAM'S CLUB Membership fees will be automatically billed to my SAM'S CLUB Personal Credit Account and my acceptance of this Account constitutes my agreement to such billing.
Federal law requires us to obtain, verify, and record information that identifies you when you open an account. We will use your name, address, date of birth, and other information for this purpose.

Signature: ____________________________________ Date:______________


WISCONSIN RESIDENTS: We are required to ask married residents of Wisconsin applying for an individual credit account to give us the name and address of their spouse, regardless of whether the spouse may use the card. Please provide that information below.

Name of Spouse:

Address of Spouse:

By signing to purchase Account Security, I acknowledge that I do not need to purchase Account Security to get credit. I have received and read the disclosures that are set forth in the Account Security Summary*. I agree that you may bill my Account a fee each month of $1.50 per $100 of the average daily balance of my Account as provided in the terms of the Account Security agreement. I may cancel at any time.

YES, I would like to purchase Account Security Debt Cancellation

Sign Here to Enroll __________________________________Date _____________

Account Security is not available for residents of Alabama and Mississippi

Credit Line
Cards Issued
Application Code
Photo ID Type
Driver's License

State ID / Matricula Consular

ID #
Expiration /Issue Date


Summary of Terms

The Account Security Program (“Program”) is optional. Whether or not you purchase the Program will not affect your application for credit or the terms of any existing credit agreement you have with Synchrony Bank (“Bank”). Upon acceptance of your enrollment in the Program, you will receive the complete Program Agreement. Please read the Agreement carefully since it provides a complete explanation of the Program. The following is only a summary of the Program, including a summary of the eligibility requirements, conditions and exclusions that could prevent you from receiving benefits under the Program.

Debt Cancellation is provided under the terms of the Program for the following events (“Covered Events”): Involuntary Unemployment, Leave of Absence, Disability, Hospitalization, Nursing Home Care, or Loss of Life with respect to the primary cardholder (the person whose name is listed first on the billing statement).

COST: The monthly fee for the Program is $1.50 per $100 of the average daily balance of your Account as provided in the Program Agreement. The fee is subject to change upon notice to you as required by law.

PROTECTIONS FOR YOU: The outstanding balance on your Account, as of the date of the Covered Event, up to $10,000, is cancelled under the terms of the Program Agreement for the following Covered Events:

INVOLUNTARY UNEMPLOYMENT: You must be involuntarily unemployed for at least 90 consecutive days. Unemployment for which you had notice within 90 days prior to enrollment in the Program or which begins within 60 days after enrollment in the Program is not covered. You must have been employed full-time in a non-seasonal occupation as of the date of involuntary unemployment, be eligible for state unemployment benefits and register within 15 days of the unemployment for work at a recognized employment agency. Unemployment caused by the following reasons is also excluded: (a) your voluntary forfeiture of employment, salary, wages or other employment income; (b) your resignation; (c) your retirement; (d) your involuntary termination of employment as the result of willful or criminal misconduct; (e) scheduled termination of your employment pursuant to an employment contract; (f) termination of seasonal employment; (g) your imprisonment; or (h) a reduction in number of hours worked that does not result in total elimination of employment income.

LEAVE OF ABSENCE: You must be on an unpaid employer approved leave of absence for at least 90 consecutive days. A leave of absence within 60 days after enrollment in the Program is not covered. You must have been employed full-time in a non-seasonal occupation as of the date the leave began.

DISABILITY: You must be disabled for at least 90 consecutive days. Disability caused by the following reasons is excluded: (a) normal pregnancy or childbirth; (b) an intentionally self-inflicted injury, whether you are sane or insane; (c) flight in non-scheduled aircraft; (d) war, declared or undeclared, including any act of war; or (e) foreign travel or residence.

HOSPITALIZATION: You must be hospitalized while under continuous care by a physician for at least 14 consecutive days. Hospitalization caused by or resulting from the following reasons will not be covered: (a) normal pregnancy or childbirth; or (b) an intentionally self-inflicted injury, whether you are sane or insane.

NURSING HOME CARE: You must be confined to a licensed nursing home while under continuous care by a physician for at least 14 consecutive days.

LOSS OF LIFE: If you die.

ENDING YOUR PROTECTION: You may terminate your enrollment in the Program at any time. If you choose to terminate within 60 days of enrollment, Bank will credit to your Account any Program fee you have been charged. Bank may terminate your enrollment in the Program by providing written notice to you. Your enrollment in the Program will terminate automatically if you fail to make any required minimum payment on your Account in any two consecutive billing periods.

HOW TO CLAIM BENEFITS: You may obtain a form to request debt cancellation by calling toll free at 1-800-644-6520 or by writing to Account Security, P.O. Box 39, Roswell, GA 30077-0039. You must also provide documents described in the Program Agreement for a particular Covered Event. In addition, you agree to provide any additional information or documents reasonably requested by Bank in connection with our review of your request for debt cancellation.


Bank reserves the right to modify the Program at any time and will provide you notice as required by law.

Cancelled debt under the Program may be taxable as income if provided by law. Please consult your tax advisor for guidance.

You must continue to make any required minimum payments on your Account after a Covered Event until the outstanding balance on your Account is paid off. A Covered Event (other than death) must occur continuously for the specified period of time before debt cancellation can be requested.

You may continue to use your Account after a Covered Event, subject to the terms of your Account Agreement. However, the amount of debt cancelled under the Program does not include purchases on your Account after the Covered Event (unless those purchases are covered due to a subsequent Covered Event while you continue to have the Program).

Any arbitration provisions that may apply with respect to your Account Agreement shall also apply with respect to the Program.

The Program is not insurance.

The Program is not available for residents of Alabama and Mississippi.

CG9A (4/05) 5326-I Rev 5/05