New Customer App Residential 02/23

ALL APPLICANTS
Name (last)
First
Middle
Date of Birth

MonthDayYear
Drivers License No.
Address

Street Address Line 2

CityState

Zip
Type a question

RENTOWN
Years present address
Home Phone
Cell Phone
SSN
Email Address
example@example.com
Present Employer
Phone Number
Years There
Position
Individual Monthly Income
Optional: Co-Applicant
Name(Last, First, Middle)
Date of Birth

MonthDayYear
Date
Drivers License Number
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
SSN
Email
example@example.com
Present Employer
Phone Number
Please enter a valid phone number.
Years There
Position
Individual Monthly Income
Has the applicant filed bankruptcy within the past seven years? If yes, provide date and location of filing.

NOYES
If the Co-op extends credit to the applicant, the applicant agrees to abide by all the terms of Belgrade Cooperative's credit policy stated on the reverse side. Everything that have stated in the application is correct to the best of my knowledge. I understand that you will retain this application whether or not itis approved. You are authorized to check my credit and employment history and to answer questions about your credit experiences with my. including obtaining a credit report on the individual applicant(s) and reporting applicant(s) performance under this Agreement to credit reporting agencies. I voluntarily agree to have my credit history reviewed at any time.

Icertify that am authorized to sign this agreement and to thereby bind the person(s) on whose behalf am signing. Customer warrants that all information submitted hereon is accurate and complete. FAXED SIGNATURE is ACCEPTABLE AND TREATED AT ORIGINAL SIGNATURE.
Applicant's Signature

Clear
Date

MonthDayYear
Date
Other Applicant's Signature (when Applicable)

Clear
Date

MonthDayYear
Date
Which commodities do you plan to purchase(check all that apply):

PropaneFuel/GasC-store Fuel/Gas, Cenex(belgrade) Credit Card
Amount of Credit Anticipated to be needed: $
Individual Consent and Certification of Taxpayer I.D. Number (form must be completed to be eligible for patronage dividends)
Name as shown on account
(Taxpayer SSN or EIN)
Mailing Address
City
State
Zip
Telephone Number
Birth Date

MonthDayYear
Date
Thereby consent to include in my gross income as now hereafter provided in the federal income tax laws, the stated dollar amount of each written notice of allocation which receive from Belgrade Co-op. With respect to my patronage occurring during the current and all subsequent taxable years of this cooperative. This consent shall be revocable by me at any time in writing.

Certification Under penalties of perjury. certify that (1) The number shown on this form is my correct taxpayer ID number (or am waiting for a number to be issued to me and(2)I amnot subject to backup withholding because: (a) am exempt from backup withholding or (b) have not been notified by the IRS that am subject to backup withholding Certification Instructions You must cross out item (2) above if you have been notified by the IRS that you are currently subject to backup withholding because of underreporting interest or dividends on your tax return. However, if after being notified by the IRS that you were subject to backup withholding. you receive another notification from the IRS that you are no longer subject to backup withholding, do not cross out item (2 The IRS does not require your consent to any provision of this document other than the certification required to avoid backup withholding.
Signature

Clear
Date

MonthDayYear
How did you hear about Belgrade Co-op?*

Website SearchBillboard/ Tank SignsFacebookNewspaper AdRadio AdChange of OwnershipCoworker/FriendBelgrade Cooperative Employee
Additional Comments:
Should be Empty:

ALL APPLICANTS