CREDIT CARD APPLICATION 
                  Credit Limit Requested: $                            Check here if this is a credit limit increase request. 
                                               (Minimum of $500)                          
       Individual Account If you are applying for an individual account in your   Joint Account If you are applying for a joint account or an account 
    own name and are relying on your own income assets and not the income or  that you and another person will use, complete all sections, providing 
    assets of another person as the basis for repayment of the credit requested,  information in CO-APPLICANT section about the joint applicant 
    complete the 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         
           SECURED/         APR FOR CASH  ANNUAL  METHOD OF 
    CARD TYPE  UNSECURED  APR FOR PURCHASES  ADVANCES/BALANCE  MEMBERSHIP  PENALTY APR  COMPUTING THE  GRACE PERIOD 
                             TRANSFER  FEE       BALANCE FOR    LATE 
                                                 PURCHASES    PAYMENT FEE  
                                                                            CASH ADVANCE 
                                                                              FEE 
     Visa                                                      $25.00        3% of the 
                                                                             amount 
    MasterCard                                                       PAYMENT BY 
          Unsecured                                                         with $10.00 
                                    $25.00                     LOST CARD  PHONE TO FSB 
                  13.20% 19.87%                                      WHEN SPEAKING 
    MasterCard                                                 REISSUE**     minimum 
                                                                       TO 
        Gold                                                   $50.00   REPRESENTATIVE 
                                                 Average              $25.00  
      Visa                                        daily 
                                                                     PAMENT OVER 
                                                 balance    3  TEMPORARY  THE PHONE TO 
    MasterCard                            22.00% *      25 Days   CREDIT LIMIT  BALANCE 
                                                                     PROCESSOR 
          Unsecured                 No Fee       including     INCREASE     TRANSFER FEE 
                  15.24% 19.87%                                      WHEN SPEAKING 
                                                                       TO 
    MasterCard                                    new             
                                                                     REPRESENTATIVE  3% of the 
                                                      2
        Gold                                    purchases      $25.00        amount 
                                                                      $10.00 
                                                                            transferred 
      Visa 
                                                               RETURNED      with a 
                                                               CHECK FEE 
    MasterCard  1                                                    RUSH CARD FEE  $10.00 
           Secured                  $50.00                        
                  19.87% 21.87%                                          
                                                                             minimum 
                                                               $29.00  $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: 02/17/2010 
    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 cardholder does not 
     meet a minimum payment for 60 days, 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. 
    1 Secured 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                                        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 
    I /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 
                                                     The amount of payment for my/our credit card to be 
    amount available in my/our account. I/We further understand and agree that First State 
                                                     deducted monthly is (check one): 
    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   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 
    
    
    
    
    
    
    
    
    
    
                                                                         
    
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                                                                            P ers o n al  Ban k i n g Sp e ci al i s t s 
                                                                          D e l i v e r c o mp l e t e d  ap p l i c a t i o n s  t o : 
                 A credit card with a perfect fit . . .