FIRST
Bank
CREDIT CARD APPLICATION
Member FDIC
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
Joint Account If you are applying for a joint account or an account that
name and are relying on your own income assets and not the income or assets of
you and another person will use, complete all sections, providing
another person as the basis for repayment of the credit requested, complete the
information in CO-APPLICANT section about the joint applicant
APPLICANT section.
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
Own/Rent/Other
Monthly Payment $
Current Address
City
State
Zip Code
How Long (yrs)
Mailing Address (If different from above)
City
State
Zip Code
How Long (yrs)
Previous Address
City
State
Zip Code
How Long (yrs)
Employer
Self Employed (Y/N)?
Work Phone
How Long (yrs)
Address
Position/Occupation
Monthly Gross Income
Name and Address of Previous Employer
How Long (yrs)
Source of Additional Income*
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
Own/Rent/Other
Monthly Payment $
Current Address
City
State
Zip Code
How Long (yrs)
Mailing Address (If different from above)
City
State
Zip Code
How Long (yrs)
Previous Address
City
State
Zip Code
How Long (yrs)
Employer
Self Employed (Y/N)?
Work Phone
How Long (yrs)
Address
Position/Occupation
Monthly Gross Income
Name and Address of Previous Employer
How Long (yrs)
Source of Additional Income*
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
Attach additional sheet if necessary.
Bank Name and Address
Branch
Loans (Yes/No, Open/Closed)
Checking Account Number/Name Listed
Savings Account Number/Name Listed
Name and Address of Creditor
Primary Name on Account
Account No.
Balance $
Monthly Payment $
Automobile
Home Mortgage
Credit Card -Bank Name & Address
CREDIT DISCLOSURES & CARD SELECTION
APR FOR CASH
SECURED/
ANNUAL
METHOD OF
CARD TYPE
APR FOR PURCHASES
ADVANCES/BALANG
MEMBERSHIP
PENALTY APR
COMPUTING THE
UNSECURED
GRACE PERIOD
TRANSFER
BALANCE FOR
LATE PAYMENT
OVER THE
FEE
PURCHASES
FEE
LIMIT FEE
CASH ADVANCE
FEE
Visa
$25.00
$30.00
3% of the
amount with
MasterCard
Unsecured
13.20%
19.87%
$25.00
$10.00
LOST CARD
PAYMENT BY
MasterCard
REISSUE**
PHONE TO FSB
minimum
Gold
$50.00
$25.00
Average
Visa
daily
balance
TEMPORARY
PAMENT OVER
MasterCard
Unsecured
15.24%
19.87%
No Fee
22.00% *
25 Days3 3
BALANCE
CREDIT LIMIT
THE PHONE TO
including
TRAMSFER FEE
INCREASE
PROCESSOR
MasterCard
new
3% of the
Gold
purchases 2
$25.00
$10.00
amount
Visa
transferred
RETURNED
with a
MasterCard
RUSH CARD
19.87%
21.87%
CHECK FEE
Secured
$50.00
$10.00
FEE
$29.00
minimum
$35.00
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
As of: 08/21/2009
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.
Secured cards are charged a one-time setup fee of $50.00
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.)
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
Date
Co-Applicant Signature
Date
BALANCE TRANSFER REQUEST
Card Types (Visa, MasterCard, JC Penny, Texaco, etc.) & Card Numbers (16 digits)
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
/We hereby authorize First State Bank to initiate withdrawals from the account
Checking/Savings Account Number
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 ABA/Routing Number
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
Bank Name and Address
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
The amount of payment for my/our credit card to be
Bank shall not be responsible for any act or failure to act on their part, except in the
deducted monthly is (check one):
case of gross negligence or willful misconduct. Furthermore, I/we agree to hold First
The minimum payment or 2% of the balance,
State Bank harmless from any claims, liabilities, attorney's fees and other costs and
whichever is greater;
The total unpaid balance;
expenses of any nature which may be incurred by reason of First State Bank's
or a
Fixed amount greater than the minimum
performance under this request.
$
X
Applicant or Co-Applicant Signature
Date