CREDIT CARD APPLICATION 
Credit Limit Requested: $ 


 Check here if this is a credit limit increase request. 
IndividualAccount 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  
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  LATE PAYMENT FEE $25.00  OVER THE LIMIT FEE $30.00  CASH ADVANCE FEE 3% of the amount with $10.00 minimum  
Visa MasterCard MasterCard  Gold  Unsecured  13.20%  19.87%  $25.00  22.00% *  Average daily balance including new purchases2  25 Days3  
LOST CARD REISSUE** $50.00  PAYMENT BY PHONE TO FSB $25.00  
 Visa MasterCard MasterCard  Gold  Unsecured  15.24%  19.87%  No Fee  TEMPORARY CREDIT LIMIT INCREASE $25.00  PAMENT OVER THE PHONE TO PROCESSOR $10.00  BALANCE TRAMSFER FEE 3% of the amount transferred with a $10.00 minimum 
 Visa MasterCard  Secured1  19.87%  21.87%  $50.00  
RETURNED CHECK FEE $29.00  RUSH CARD FEE $35.00  

X 

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: 08/21/2009contact 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 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. $ ________.  

Applicant or Co-Applicant Signature Date 
A credit card with a perfect fit . . . 


that�s freedom banking. 
Card CreditApplication 


575.835.1550 www.SocorroBanking .co m 103 Manzanares Avenue 
Deliver completed applications to: Personal Banking Specialists First St ate Bank 
O. P.Box Z Soco rro , NM 87801 -0479