Farmers State Bank

Consumer Credit Card Application

Important information about procedures for opening an account:

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

Married WI Residents: If you are applying for an individual account or a joint account with someone other than your spouse, and your spouse also lives in Wisconsin, combine your financial information with your spouse's financial information. You understand that we may be required to notify your spouse of this account. Married Wisconsin residents must furnish their (the applicant's) name and social security number as well as the name and address of their spouse to TIB, National Association at P.O. Box 569120, Dallas, TX 75356-9120.

Card Selection

Card Selection:

If you would like to attach any other documentation, please use the "Choose Files" button below.

Please click this button, and then choose the files to attach to this application.
To attach more than one file, hold down the Ctrl key, and then click on each file.

Applicant Information

First Name

Middle Initial

Last Name

Mother's Maiden Name (For Security Purposes)

Birth Date

Social Security Number

Own Home

Rent Home

Street Address

City

State

Zip Code

Years at Address

Home Phone

Previous Street Address

City

State

Zip Code

Years at Previous Address

Name of Employer or Source of Income

Position or Title

Business Phone Extension

Years at Employer or Source of Income

Gross Monthly Income*

$ .00

Other Income*

$ .00

Source of Other Income

*Alimony, Child Support or Separate Maintenance Income need not be revealed if you do not wish it to be considered as a basis for repaying this obligation.

Authorized Users (optional)

We'll send a personal card for each authorized user.

Authorized User 1 Enter your name as it would appear on a government issued ID.

First Name

Middle Initial

Last Name

Authorized User 2 Enter your name as it would appear on a government issued ID.

First Name

Middle Initial

Last Name

Signature

LOAN APPLICATION CERTIFICATION: Everything that I have stated in this application is correct to the best of my knowledge. I understand that this application will remain your property and you will retain it whether or not this application is approved.

This application is submitted to obtain credit. You are authorized to check my employment history and to ask questions about my credit experiences. Without limiting the foregoing, I authorize you to make inquiries (including requesting reports from consumer credit reporting agencies and other sources) to verify my identity and determine my eligibility for credit, and subsequently in connection with any extension of credit, update, renewal, review or collection of my account or for any other legal purpose. I understand that, on my request, you will tell me whether or not you requested a credit report and the names and addresses of any credit bureaus that provided you such reports. I also authorize you to release information to others about my history with you. I understand that you may report information about my account to credit bureaus. Late payments, missed payments, or other defaults on my account may be reflected in my credit report.

STATE LAW DISCLOSURES: CA Residents: Regardless of your marital status, you may apply for credit in your name alone. If this is a joint account, after credit approval each applicant has the right to use this account to the extent of any credit limit set by the creditor, and each applicant may be liable for all amounts of credit extended under this account to any joint applicant. DE and MD Residents: Service charges not in excess of those permitted by law will be charged on the outstanding balances from month to month. NY Residents: New York residents may contact the New York State Banking Department (1-800-342-3736) to obtain a comparative listing of credit card rates, fees, and grace periods. OH Residents: The Ohio laws against discrimination require that all creditors make credit equally available to all credit worthy customers, and that credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio Civil Rights Commission administers compliance with this law. Married WI Residents: No provision of a marital property agreement, a unilateral statement under section 766.59, or a court decree under section 766.70 adversely affects the interest of the creditor unless the creditor, prior to the time the credit is granted, is furnished a copy of the agreement, statement, or decree or has actual knowledge of the adverse provision when the obligation to the credit is incurred.

Electronic Signature Authorization:

Where prompted, clicking "Applicant Confirms Signature," you agree to conduct each transaction by electronic means, and TIB, National Association and you hereby state that electronic signatures shall have the same force and effect as original signatures with respect to these Rates, Charges, Fees and Terms of Conditions and all written agreements entered into between you and TIB, National Association.

Rates, Charges, Fees and Terms of Conditions

Applicant Confirms Agreement with Rates, Charges, Fees and Terms of Conditions

Applicant Signature

Signature Date

Applicant Confirms Signature

INTERNAL USE ONLY

Employee code:

E-mail address: