BUSINESS CREDIT APPLICATION AND AGREEMENT

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  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)                    

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:              

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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            

References  

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  

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                            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:                   Date:           By:                        

Title:                        

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.  

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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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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

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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  

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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  

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References

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