Industry State Bank
CREDIT CARD APPLICATION
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Attention: Fill out the form on your computer then print it. Sign the bottom of the form and then either fax or mail the form to the fax no. or location provided below.

Applicant(s) is required to present identification and sign the final documentation in the presence of a bank officer.
Industry
New Ulm
PO Box 66
Industry, TX 78944
 Fax 979-357-4735
Phone 979-357-4437		 PO Box 155
New Ulm, TX		 Fax 979-992-3996
Phone 979-992-3391

Application Information
Marital Status:
  
First Name
  
Last Name
  
e-mail Address
  
Social Security #
 
Date of Birth (mm/dd/yy)
  
Place of Birth
 
Are you a US Citizen?
  yes     no
Street Address
  
City, State
 ,  
Zip-Plus 4
-
Home Phone Number
  -
Years at this Residence
  
Employer
  
Occupation
  
Salary
       Per 
Work Phone Number
  -
Length of Employment
   years       months
Present net salary or commissions: $ per
No. Dependents: Ages:
Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
Alimony, child support, separate maintenance received under:
court order:
written agreement:
oral understanding:
Other Income (per month)
Source(s) of other Income
Other income: $ per
Source(s) of other income:
Is any income listed in this Section likely to be reduced is the next two years?
Yes(Explain in detail on a separate sheet.) No
Contingent Liabilities
Do you have any contingent liabilities? If yes, give details:     yes     no
Are you an endorser, guarantor or co-maker for others?    yes     no If yes, please list creditor's name, borrower's name and account number.
Any judgment, bankruptcy, garnishment, legal proceedings against you? If yes, list type of proceeding and date.    yes     no
Are any assets pledged? If yes, list type of proceeding and date.    yes     no
Use the box below to list any additional information or requests
I acknowledge that I have made this application with the intent that Industry State Bank should rely upon the information contained herein in granting the credit requested. I understand that, if the requested information is granted, Industry State Bank may report information concerning the credit to consumer reporting agencies and to others. I affirm that my answers are complete and true and authorize Industry State Bank to verify or obtain any information concerning them. Upon Industry State Banks request, I further authorize any firm or individual from whom I may have obtained or requested credit, to furnish the details of that transaction. I also agree to provide current financial information upon request, in a form that is acceptable.
First Account holders signature :

X _______________________________________

Second Account holders signature :

X _______________________________________
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