BUSINESS CREDIT APPLICATION AND AGREEMENT

Transcription

1 BUSINESS CREDIT APPLICATION AND AGREEMENT Please print or type Date: Business name: Address: Street City State Zip Business phone: ( ) Fax ( ) Business Website: Name of Authorized RepresentaCves: Title RepresentaCve s Home Address: RepresentaCve s Phone ( ) Street city state zip Federal I.D. No. State sales tax to be collected: Yes: No: If no, list State Sales Tax Resale CerCficaCon No. Dunn and Bradstreet No. Billing Address (if different): Shipping Address (if different): Management Company (if apartments) Company Informa;on Type of Business: Sales: Service: Other: Apts: # units Are purchase order numbers required on all invoices? Yes No Accounts payable contact: Phone ( ) Dollar amount of escmated purchase/charges per month:

2 Date your business was established: How long at current Business address: If less than one year, Please give previous business address and previous business name, if applicable: Is your business (please check one) Sole Proprietorship: Partnership: LLC: CorporaCon: If LLC or CorporaCon, date of organizacon/incorporacon: If sole proprietor: Name Home Address Phone Social Security No. If partnership, LLC or corporacon, list partners/members/officers: Name Title Home Address/Phone S.S. No If Division/subsidiary, name of parent company: Parent company s business address: Date parent company was established: Name of company principal responsible for business transaccons: Business s Annual Revenue: Number of Employees References Trade References: Name, Address, Phone, Fax Number, Address and Account No Bank References: List informacon for principle bank 1. Name of bank Address

3 Phone Number Account Number Account officer 2. Name of Bank Address Phone Number Account No. Account Officer AGREEMENT I herein make applicacon to United prairie CooperaCon for credit. I hereby cercfy that the informacon contained herein is complete and accurate. This informacon has been furnished with the understanding that it is to be used to determine the amount and condicons if the credit to be extended. If credit is granted, I promise to pay all bills when rendered. If credit is granted, I hereby agree to all terms of condicons of United Prairie CooperaCve s Credit policy. If suit of accon by an aaorney is insctuted, I promise to pay all reasonable aaorney fees in said suit of accon. The undersigned shall not transfer or assign this agreement without the prior wriaen consent of United Prairie CooperaCve and/or its agents to verify or supplement the informacon stated hereon this Credit ApplicaCon. I give my permission for all companies and banks to release my credit history to assist you in determining whether and/or how much credit may be extended to me by United Prairie CooperaCve. If this is a personally owned encty we authorize you to do personal credit check on individual owners. In consideracon of United Prairie CooperaCve extending credit, it is required for all applicacons that the applicants provide to United Prairie CooperaCve either a leaer of credit from a recognized lending insctucon or earnest money/down payment, which will be applied to the business s account in advance. The only excepcons made to this requirement will be at the sole discrecon of management and instead of a leaer of credit or earnest money/ down payment, will be in the form of a personal guaranty from the applicant. The amount required for the leaer of credit or earnest money/down payment or personal guaranty will be based on the amount of the credit that is requested and approved. Business name: By: Title: Date: CONTINUING PERSONAL GUARANTEE For the purpose of extending credit for the firm applying for credit listed above, the undersigned hereby absolutely and uncondiconally guarantees, on a concnuing basis, payment of all present and future indebtedness.

4 This personal guarantee shall remain in effect uncl terminated by the undersigned by wriaen nocce to United Prairie CooperaCve, in which event said guarantee shall scll be applicable to any indebtedness of the firm listed above incurred prior to the date such nocce is received by United Prairie CooperaCve. Guarantor Date INDIVIDUAL CONSENT AND CERTIFICATION OF TAXPAYER I.D. NUMBER Name (as shown on Income Tax Return): Taxpayer ID No. (SSN or EIN): Billing Address: Street City State Zip Phone: ( ) Date of Birth: I hereby consent to include in my gross income, as now or hereafer provided in the federal income tax laws, the state dollar amount of each wriaen nocce of allocacon which I receive from UNITED PRAIRIE COOPERATIVE - NEW TOWN, NORTH DAKOTA, with respect to my patronage occurring during the current and all subsequent taxable years of this cooperacve. This consent shall be revocable by me at any Cme, if in wricng. Signature: Date: CERTIFICATION: Under penalces of perjury, I cercfy that (1) The number shown on this form is my correct taxpayer idencficacon number (OR I AM WAITING FOR A NUMBER TO BE ISSUED TO ME), and (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been nocfied by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has nocfied me that I am no longer subject to backup withholding.certification InstrucCons: You must cross out item (2) above, if you have been nocfied by the IRS that you are currently subject to backup withholding because of under- reporcng interest or dividends on your tax return. However, if afer begin nocfied by the IRS that you were subject to backup withholding, you received another nocficacon from the IRS that you are no longer subject to backup withholding, do not cross out item (2).The Internal Revenue Service does not require your consent to any provision of this document, other than the cercficacons required to avoid backup withholding. blh.1.018

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7 Card Order Form Name/Company Name: Account Number with United Prairie: Number of cards you will need: Patronage Only Cards: Fuel Restrictions(Listed Below): Driver ID(Pin Number Four Digits #) Card #1: Card #2 Card #3 Card #4 Card #5 If additional card are need please list on a separate sheet. Fuel Restrictions 0 = Anything 1 = Clear Diesel Only 2 = Dyed Diesel Only 3 = Gasoline Only

8 4 = Clear and Dyed Diesel Only If you have any question, please contact the Main Office CARDHOLDER AGREEMENT This agreement is made and entered into this day of, 20, by and between United Prairie CooperaCve, New Town, North Dakota, hereafer referred to as CooperaCve and, account number, hereafer referred to as Patron. 1. Patron understands that this facility shall be for private use by designated cardholders only, and not open to the public. 2. If card is lost or stolen, Patron must nocfy CooperaCve. UnCl this is done, Patron is responsible. 3. Patron acknowledges instruccons as to proper use of the dispensing equipment. 4. Patron further agrees to limit the use of the above dispensing equipment to persons who have been instructed and qualified in the use of such equipment by CooperaCve s manager or persons so designated by such Manager for that purpose. 5. Patron agrees not to leave the dispensing equipment unaaended at any Cme while it is being operated and to accept the responsibility of controlling sources of ignicon. Patron further agrees not to dispense Class 1 liquids into containers not in compliance with the State Fire Code. 6. PATRON AGREES TO COMPLY WITH THE CREDIT POLICY OF COOPERATIVE. The credit policy of this stacon is payment in full within ten (10) days of the statement cut- off date, which is the last day of each month. Failure to comply with payment of your account will result in automacc invalidacon of your operacng card and immediate COD of your account. In addicon, our present credit policy, which includes an annual finance charge on past due amounts over 30 days old, applies to all accounts! Patron also understands that the price to be paid for fuels dispensed may vary and be changed without nocce by CooperaCve. 7. Patron understands and agrees that any violacon of the terms of this agreement shall consctute authority for the CooperaCve to immediately, and without nocce, terminate this agreement and the use of the facilices herein described. Patron also may terminate this

9 agreement at any Cme by the return of the card(s) to CooperaCve with payment in full for products purchased. 8. There will be no excepcons to this agreement! Credit Approval Signature Date