Personal Credit Application

Is this Application a Sole (Single) Application or Joint Application?

Sole ApplicationJoint Application

Will this account be for Farm/Agro Use?

YesNo

Riverbend Co-op Number*

Name*

What is your e-mail address?*

Date of Birth*

Date

Social Insurance Number (optional)

Mailing Address (PO Box#) *

City & Province

Home Phone*

Postal Code*

Business Phone

Former Address (if less than 1 year)

Cell Phone

Previous Account with Riverbend?

YesNo

If you had a Previous Account - How long ago?

Spouse’s Name

Spouse’s Date of Birth

Date

Spouse’s Social Insurance Number (Optional)

Present Employer

How Long?

Address (Mailing Address, City, Province)

Previous Employer

How Long?

Address (Mailing Address, City, Province)

Name of Bank, Credit Union or Finance Company

Type of Account

Address (Mailing Address, City, Province)

Legal Land Description (Section, Township, Range, West of Meridian)

Location of Livestock (Section, Township, Range, West of Meridian)

Is Livestock Financed by Third Party? (Yes/No)

If livestock is financed, who is the financing company?

Number and Type of Livestock

Do you own your land?

YesNo

Is your land mortgaged, if so by who?

Do you Rent your Land?

YesNo

Name of Landlord

Other Current or Previous Accounts

I/we understand that purchases made during a calendar month of this Co-op account are payable in full by the last day the following month. On any amount that is not paid, I/we agree to pay a service charge of 24% per annum (2.0% per month) calculated monthly and added to the account until the account has been paid in full or made current within the terms arranged and I/we shall be responsible for collection costs incurred in recovering the full amount of my unpaid account. Any payments on this account which do not pay the account in full will be applied firstly, to pay service charges and secondly, to reduce the principal outstanding.

The issue to me/us of my Co-op account shall constitute an agreement on the Co-op’s part to extend credit to me on the above terms, which may be amended from time to time and arranged limit.

I/we will be responsible for all goods or services charged to my/our account until I/we have notified the Co-op Credit Department in writing.

I/we hereby apply for credit with the Co-op, subject to the terms outlined above with a credit limit of:

Credit Limit Desired:*

I/we certify the above information to be true and correct and hereby agree by singing below to the obtaining of such information as the Co-op may require from any credit reporting agency or any person with whom I/we have or may have financial relations. I/we assume full responsibility for all purchases.

DATE:*

Date

Signatures (can sign using mouse or finger on smart phone)*

MM DD YY

Co-Applicant Signature

Personal Credit Application

AGRO COMPLETE THIS PORTION ONLY FOR FARM USE

Please Read, Date and Sign