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: Street city state zip RepresentaCve’s Phone ( ) 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)
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:
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
1. 2. 3. 4. 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
Trade References: Name, Address, Phone, Fax Number, Email Address and Account No.
1. 2. 3. 4. Bank References: List informaCon for principle bank
1. Name of bank Address
Phone Number Account Number Account oﬃcer
2. Name of Bank Address
Phone Number Account No. Account Oﬃcer
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: Date: By:
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.
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.
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
Card Order Form
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.
0 = Anything
1 = Clear Diesel Only
2 = Dyed Diesel Only
3 = Gasoline Only
4 = Clear and Dyed Diesel Only
If you have any question, please contact the Main Office
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
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