CREDIT CARD APPLICATION 

Credit Limit Requested: $                    

 Check here if this is a credit limit increase request. 

 Individual Account If you are applying for an individual account in your own 
name and are relying on your own income assets and not the income or assets of 
another person as the basis for repayment of the credit requested, complete the 
APPLICANT section.  

 Joint Account If you are applying for a joint account or an account that 

you and another person will use, complete all sections, providing 
information in CO-APPLICANT section about the joint applicant 

Note: All applicable sections should be complete otherwise, processing of your application may be delayed.   

RECEIVED DATE:            

APPLICANT  
Last Name  

First Name  

Middle  

Social Security Number  

Date of Birth  

No. of Dependents  

Home Phone # 

Mobile Phone # 

Mother’s Maiden Name 

Email Address 

Current Address  

Mailing Address (If different from above)  

Previous Address  

Employer  

Address  

Name and Address of Previous Employer  

Source of Additional Income*  

City  

City  

City  

Own/Rent/Other 

Monthly Payment $ 

State  

State  

State  

Zip Code  

How Long (yrs)  

Zip Code  

How Long (yrs) 

Zip Code 

How Long (yrs)  

Self Employed (Y/N)?  

Work Phone  

How Long (yrs)  

Position/Occupation  

Monthly Gross Income 

How Long (yrs)  

Amount per Month $  

Nearest Relative (Not Living With You)  

Home Phone  

Relationship  

Their Address  

City  

State  

Zip Code  

*You are not required to furnish alimony, child support, or maintenance income information if you do not want us to consider it in evaluating your application 

CO-APPLICANT  
Last Name  

First Name  

Middle  

Social Security Number  

Date of Birth  

No. of Dependants  

Home Phone # 

Mobile Phone # 

Mother’s Maiden Name 

Email Address 

Current Address  

Mailing Address (If different from above)  

Previous Address  

Employer  

Address  

Name and Address of Previous Employer  

Source of Additional Income*  

City  

City  

City  

Own/Rent/Other 

Monthly Payment $ 

State  

State  

State 

Zip Code  

How Long (yrs)  

Zip Code  

How Long (yrs) 

Zip Code 

How Long (yrs) 

Self Employed (Y/N)?  

Work Phone  

How Long (yrs) 

Position/Occupation  

Monthly Gross Income 

How Long (yrs) 

Amount per Month $  

Nearest Relative (Not Living With You)  

Home Phone  

Relationship  

Their Address  

City  

State  

Zip Code  

*You are not required to furnish alimony, child support, or maintenance income information if you do not want us to consider it in evaluating your application.  

CREDIT INFORMATION  
Bank Name and Address  

Branch  

   Attach additional sheet if necessary.  
Loans (Yes/No, Open/Closed)  

Checking Account Number/Name Listed  

Savings Account Number/Name Listed  

Name and Address of Creditor  
Automobile  

Home Mortgage 

Credit Card -Bank Name & Address 

Primary Name on Account  

Account No.  

Balance $    

Monthly Payment $  

CREDIT DISCLOSURES & CARD SELECTION  

CARD TYPE 

SECURED/ 
UNSECURED 

APR FOR PURCHASES 

APR FOR CASH 
ADVANCES/BALANCE 
TRANSFER 

ANNUAL 
MEMBERSHIP 
FEE 

PENALTY APR 

METHOD OF 
COMPUTING THE 
BALANCE FOR 
PURCHASES 

GRACE PERIOD 

Visa 

MasterCard 

MasterCard    
    Gold 

 Visa 

MasterCard 

MasterCard    
    Gold 
 Visa 

Unsecured  13.20%  19.87%  $25.00 

Unsecured  15.24%  19.87%  No Fee 

22.00% * 

MasterCard  Secured1  19.87%  21.87%  $50.00 

LATE PAYMENT 
FEE  

OVER THE 
LIMIT FEE  

$25.00 

$30.00 

LOST CARD 
REISSUE** 
$50.00  

PAYMENT BY 
PHONE TO FSB 
$25.00  

CASH ADVANCE 
FEE 
3% of the 
amount with 
$10.00 
minimum 

Average 
daily 
balance 
including 
new 
purchases2 

25 Days3 

TEMPORARY 
CREDIT LIMIT 
INCREASE 

PAMENT OVER 
THE PHONE TO 
PROCESSOR 

$25.00 

$10.00 

RETURNED 
CHECK FEE 

$29.00 

RUSH CARD 
FEE 

$35.00  

BALANCE 
TRAMSFER FEE 

3% of the 
amount 
transferred 
with a 
$10.00 
minimum 

      
 
 
 
           
           
           
           
           
       
           
         
           
           
           
           
           
           
     
           
       
           
           
     
           
       
           
           
     
            
       
           
       
           
       
           
           
           
           
       
           
           
           
           
           
           
           
     
           
           
           
           
           
           
       
           
           
           
           
           
           
           
           
     
           
       
           
           
     
           
        
           
           
      
            
        
           
       
           
        
           
           
           
           
        
           
           
           
           
           
           
           
     
           
 
 
 
 
 
 
 
           
           
           
           
           
           
           
           
           
           
            
           
           
           
           
            
           
           
           
           
 
 
 
 
   
 
 
 
 
 
 
 
As of: 08/21/2009 

DISCLOSURES 
At the date this application was created (shown at right) the information listed above was accurate. Because rates and terms are subject to change, you may 
contact us for the current information by writing to First State Bank; Bank Credit Card Department; PO Box Z; Socorro NM 87801-0479, Phone: 575-835-1550 
 *If the minimum required payment is not received within one (1) day after the Closing Date subsequent to the payment Due Date the account is past due, if the account is past due  
    twice in a six month period, the rate will adjust to the penalty rate for a period of six months of current history.  
**If lost twice in a six month period. 
1Secured cards are charged a one-time setup fee of $50.00 
2 The finance charge for a billing cycle is computed by applying the monthly periodic rate to the average daily balance of credit purchases, which is determined by dividing the sum of 
the daily balances during the billing cycle by the number of days in the cycle. Each daily balance of credit purchases is determined by adding to the outstanding unpaid balance of 
credit purchases at the beginning of the billing cycle any new credit purchases posted to your account, and subtracting any payments as received and credits as posted to your 
account, but excluding any unpaid finance charges. (A finance charge will be assessed on cash advances and or Balance Transfers from the date of the cash advance and or Balance 
Transfer, or the first day of the billing cycle in which the cash advance and or Balance Transfer is posted, whichever is later, and will continue to accrue until payment in full is posted.)  
3 A finance charge will be imposed on credit purchases only if you elect not to pay the entire new balance shown on your monthly statement for the previous billing cycle within 25 
days from the closing date of that statement. If you elect not to pay the entire new balance shown on your previous monthly statement within that 25-day period, a finance charge will 
be imposed on the unpaid average daily balance of such credit purchases from the previous statement closing date on new credit purchases from the date of posting to your account 
during the current billing cycle, and will continue to accrue until the closing date of the billing cycle preceding the date on which the entire new balance is paid in full or until the date of 
payment if more than 25 days from the closing date. 
International transaction fee/currency conversion: If cardholder incurs charges in any other currency, the charges will be converted into US dollars. MasterCard’s or VISA’s 
currency conversion procedure includes use of either a government mandated exchange rate, or a wholesale exchange rate selected by MasterCard or VISA, and the rate 
MasterCard or VISA uses for a particular transaction is a rate selected by MasterCard or VISA for the applicable currency on the day the transaction is processed, which may differ 
from the rate applicable on the date the transaction occurred or the date on which the transaction is posted to the cardholders account. Cardholder agrees to pay the converted 
amount to issuer in US dollars, plus a fee of 1% for conversion and processing imposed by First State Bank and MasterCard or VISA. 
Travel Accident Insurance: You, your spouse and dependent children up to age 19 (age 25 if a full-time student at any institute of higher learning) are automatically covered with 
common carrier travel accident insurance every time you travel by air, bus, train, ship, taxi or any other common carrier anywhere in the world when you charge your entire fare to our 
card. This coverage is provided to you at NO EXTRA COST. 
INSURANCE SALES DISCLOSURE 
In connection with certain types of loans that we offer, we may require you to provide insurance. However, as a borrower, you are not required to purchase any insurance 
offered by the bank or by any of its affiliates. You may purchase the insurance that the bank may require from any approved provider. You should know that the bank may 
not condition an extension of credit on either: your purchase of an insurance product or annuity from the bank or any of its affiliates; or your agreement not to obtain, or 
a prohibition of the consumer from obtaining an insurance product or annuity from an unaffiliated entity. 
SIGNATURE(S) 
PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING: This statement is submitted to obtain credit and I/we certify that all information herein is true and 
complete. I/We agree that an inquiry may be made to verify information and that credit references or verification may be given based on inquiries from other parties. This 
offer is subject to the credit policies of First State Bank. I/We agree to be bound by the terms and conditions of the bank card agreement, a copy of which will be mailed to 
the applicant if this application is granted, receipt of such agreement and acceptance of such terms to be conclusively presumed by the applicant’s use. If this is a joint 
application, the undersigned shall be jointly and severally liable for any and all credit extended from time to time. I/we also understand the contents of the insurance sales 
disclosure. 

Joint credit notice (this box must be checked if you are applying for joint credit):  We intend to apply for joint credit. 
X 
Applicant Signature  
BALANCE TRANSFER REQUEST 
Card Types (Visa, MasterCard, JC Penny, Texaco, etc.) & Card Numbers (16 digits) 

X 
Co-Applicant Signature 

Date 

Date 

Upon approval, I wish to transfer my present 
balance on the credit card account(s) listed below 
to my new FSB credit card account. I will send a 
copy of the latest statement from each card 
issuer to First State Bank. I understand that I can 
only transfer balances up to the limit on my new 
credit card. 
X 
Applicant or Co-Applicant Signature    

Date 

AUTOMATIC PAYMENT REQUEST 
I /We hereby authorize First State Bank to initiate withdrawals from the account 
indicated to pay my/our new credit card account by completing this section and signing 
below. This authority is to remain in full force and effect until I/we provide First State 
Bank with a written authorization requesting that a change be made or that the periodic 
payment be terminated. I/We must provide this written authorization for changes or 
termination to First State Bank at least 30 days prior to the effective date of the 
requested change or termination. I/we understand and agree that in order for First 
State Bank to make the payments requested herein, I/we must have the payment 
amount available in my/our account. I/We further understand and agree that First State 
Bank shall not be responsible for any act or failure to act on their part, except in the 
case of gross negligence or willful misconduct. Furthermore, I/we agree to hold First 
State Bank harmless from any claims, liabilities, attorney’s fees and other costs and 
expenses of any nature which may be incurred by reason of First State Bank’s 
performance under this request. 

X 
Applicant or Co-Applicant Signature 

Checking/Savings 

Account Number 

Bank ABA/Routing Number 

Bank Name and Address 

The amount of payment for my/our credit card to be 
deducted monthly is (check one): 

 The minimum payment or 2% of the balance, 

whichever is greater; 
or a  

 The total unpaid balance; 
 Fixed amount greater than the minimum  

$          ________. 

Date 

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