a subsidiary of FIRST STATE BANK

Please check if you do NOT want your current employer contacted.

Are you a citizen of the United States?

If no, are you authorized to work in the U.S.?YES

Have you ever worked for this company?YES

Please list three professional references.

May we contact your present employer?YESNO

May we contact your previous supervisor for a reference?

May we contact your previous supervisor for a reference?

May we contact your previous supervisor for a reference?

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Applicant's Statement I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 180 days. If I wish to be considered for employment beyond this time period, I understand that I need to inquire as to whether or not applications are being accepted at that time. I understand that neither this document nor any offer of employment from the employer constitutes an employment contract unless a specific document to that effect is executed by the employer and me inwriting. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Applicant Data Request Card Thank you for applying at First State Mortgage Services, LLC. Your resume is being carefully considered. We will contact you if your qualifications meet our needs. Attached is an Equal Employment Opportunity Survey. In order to meet our affirmative action objectives and to comply with the Federal and/or State law requirements, you are invited to provide the information requested below. Providing this information is voluntary. Your application for employment will not be adversely affected based upon your decision to respond or decline to respond. Please return the EEO Survey via email, fax or by mail to the address below. Ethnic Group* (Mark one category) Hispanic or Latino

Native Hawaiian or Other Pacific Islander

United States Permanent Resident

NOTE: Suporting documentation (DD214/DD215 and, for Disabled Veterans, a copy of your veterans' disability preference letter from the Department of Veterans' Affairs unless that information is included in the DD214/215 form) MUST be submitted to establish eligibility.

Person with a Disability (ADA Regulations)*: If you are a qualified individual with a disability* and you need reasonable accommodation to participate in the hiring process or in employment if hired for this position, please contact Lydia Walk. Tel: (309) 664-7038; Fax (309) 664-7038; Email: lwalk@fsmloans.biz.

Self-Identification Descriptions

Hispanic or Latino -A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race. White, not of Hispanic Origin -A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American, not of Hispanic Origin -A person having origins in any of the black racial groups of Africa.

Asian, not of Hispanic Origin -A person having origins in any of the original peoples of the Far East, Southeast Asia, including, for example, Cambodia, China, Japan, Korea, Malaysia, the Philippine Islands, Thailand, and Vietnam.

NHOPI. Native Hawaiian or Other Pacific Islander, not of Hispanic Origin -A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. American Indian or Alaskan Native, not of Hispanic Origin -A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. Qualified Individual with a Disability is an individual with a disability as defined under the Americans with Disabilities Act who satisfies the requisite skill, experience, education and other job-related requirements of the employment position held or desired and is able to perform the essential functions of that position, either with or without reasonable accommodation.

Disabled Veteran is a person entitled to disability compensation under laws administered by the United States Department of Veterans Affairs for disability rated 30 percent or more, a person whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty.

Please return this form via one of the following methods: Via Mail: First State Mortgage Services, LLC Attn: Lydia Walk 502 North Hershey Road, Bloomington, IL 61704 Via fax: (309) 807-0238 Email: lwalk@fsmloans.biz

Authorization: By signing below, you authorize: (a) General Information Services, Inc. ("GIS") to request information about you from any public or private information source; (b) anyone to provide information about you to GIS; (c) GIS to provide us ( ) one or more reports based on that information; and (d) us to share those reports with others for legitimate business purposes related to your employment. GIS may investigate your education, work history, professional licenses and credentials, references, address history, social security number validity, right to work, criminal record, lawsuits, driving record, credit history, and any other information with public or private information sources. You acknowledge that a fax, image, or copy of this authorization is as valid as the original. You make this authorization to be valid for as long as you are an applicant or employee with us. The Consumer Financial Protection Bureau's "Summary of Your Rights under the Fair Credit Reporting Act" is attached to this authorization. If you are a New York applicant, a copy of New York's law on the use of criminal records is attached. By signing below, you acknowledge receipt of these documents.

Personal Information: Please print the information requested below to identify yourself for GIS.

from Mo/Yr Some government agencies and other information sources require the following information when checking for records. GIS will not use it for any other purposes.

Name as it appears on license Report Copy: If you are applying for a job or live in California, Minnesota, or Oklahoma, you may request a copy of the report by checking this box:

Sample Consumer Authorization | Last modification date: 2/7/2013

We ( reports (or both) about you for employment purposes. These purposes may include hiring, contract, assignment, promotion, re-assignment, and termination. The reports will include information about your character, general reputation, personal characteristics, and mode of living. We will obtain these reports through a consumer reporting agency. Our consumer reporting agency is General Information Services, Inc. GIS's address is P.O. Box 353, Chapin, SC 29036. GIS's telephone number is (866) 265-4917. GIS's website is at www.geninfo.com, where you can find information about GIS's international privacy practices. To prepare the reports, GIS may investigate your education, work history, professional licenses and credentials, references, address history, social security number validity, right to work, criminal record, lawsuits, driving record, credit history, and any other information with public or private information sources.

) will obtain one or more consumer reports or investigative consumer

You may obtain a copy of any report that GIS provides and GIS's files about you (in person, by mail, or by phone) by providing identification to GIS. If you do, GIS will provide you help to understand the files, including trained personnel and an explanation of any codes. Another person may accompany you by providing identification. If GIS obtains any information by interview, you have the right to obtain a complete and accurate disclosure of the scope and nature of the investigation performed Please sign below to acknowledge your receipt of this disclosure.

Sample Consumer Disclosure | Last modification date: 2/7/2013