NAME ___________________________________________________

ADDRESS  __________________________________________________

CITY __________________________   STATE _________   ZIP ________

SSN# ___________________________________________________

DATE OF BIRTH ____________

HOME PHONE _______________________________________________

WORK PHONE ____________________________________________

CELL PHONE ____________________________________________

SIGNATURES: By signing below, the undersigned request(s) the described services and agrees to the terms and conditions governing the services, including any fees and charges, and acknowledges a copy thereof. The undersigned agree(s) that all information is accurate and authorizes Fairfax State Savings Bank to verify credit and employment history by any necessary means, including preparation of a credit report by a credit reporting agency. Must be 18 years of age to apply.

___________________________________________________________
APPLICANT'S SIGNATURE                                           DATE

ACCOUNT NUMBER ___________________________________________

ACCOUNT NUMBER ___________________________________________

FOR BANK USE ONLY

PAN#______________________________________________________

INT ______   DATE _____________     INT ______   DATE _____________