Personal Credit Application

Personal Credit Application
LAKE COUNTRY CO-OPERATIVE ASSOCIATION LTD.
791 - 801 15th Street East Prince Albert, Saskatchewan S6V 0C7

Phone: 306-764-9393306-862-4668
Email: credit@lakecountrycoop.ca www.lakecountryco-op.crs
CO OP NUMBER*
PERSONAL / NON-CORPORATE FARM CREDIT APPLICATION
FULL NAME*

First NameLast Name
MIDDLE NAME INITIALS
DATE OF BIRTH*

MonthDayYear
Date
APT. #
MAILING ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your current mailing address the same as your physical address?
PHYSICAL ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PRIMARY PHONE NUMBER*
Please enter a valid phone number.
BUSINESS PHONE
Please enter a valid phone number.
EMAIL*
example@example.com
*By providing your email you give Lake Country Co-op permission to use this address for communication.

EMPLOYER*
OCCUPATION*
HOW LONG*
EX: 3 years
YOUR MONTHLY NET INCOME*
SIN*
RELATIONSHIP STATUS*

SingleCommon LawMarriedSeparatedDivorcedWidowed
SPOUSE'S FULL NAME

First NameLast Name
SPOUSE'S DATE OF BIRTH

MonthDayYear
Date
SPOUSE'S EMPLOYER
SPOUSE'S OCCUPATION
HOW LONG
EX: 3 years
SPOUSE'S MONTHLY NET INCOME
SPOUSE'S SIN
NAME OF NEAREST RELATIVE NOT LIVING WITH APPLICANT*

First NameLast Name
PHONE*
Please enter a valid phone number.

SECTION B:
ACCOUNT NO
BANK OR CREDIT UNION*
BRANCH*
ACCOUNT NUMBER
ACCOUNT TYPE

CHEQUINGSAVINGS
HOME FINANCED BY
ESTIMATED VALUE
AMOUNT OWING
MONTHLY PAYMENT / RENT
REASON FOR ACCOUNT?*
CREDIT LIMIT REQUESTED*
REGULAR CHARGE CARDS blanks# OF CARDS.

CARDLOCK CARDS blank# OF CARDS.
DYED FUEL PERMIT #
CREDIT POLICY
Accommodation Credit: Accounts are set up as Net 30 days. Interest will be charged on the last day of the month following date of purchase. IE: Purchased in June, interest will be charged last day of July. Interest charged on overdue accounts is 24% per annum calculated at 2% per month compounded (26.8% effective rate Credit privileges are suspended once the account is over 90 days old. Credit cards cannot be accepted as payment on account.
RETURNED CHEQUES
There is a $50.00 charge for each returned cheque.
AGREEMENT
By selecting the “I agree” button, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian. I understand that the electronically stored copy of my signature, any written instruction or authorization, and any other document provided to me is considered to be the true, accurate, and complete record, legally enforceable in any proceeding to the same extent as if such documents were originally generated and maintained in printed form. I agree not to contest the admissibility or enforceability of the electronically stored copy of this document and any other documents. I agree to the terms and conditions of this document on behalf of myself or as the parent or legal guardian of the minor on whose behalf I am signing this document.*

I agree
I certify that the above information is true and, if this application is accepted, I agree to abide by the credit and cheque cashing policy of Lake Country Co-operative Association Limited and pay interest on overdue accounts as stated. I certify that I am entering into this agreement primarily for personal, family, household or non-corporate farming purposes.

I, the undersigned, agree that the Co-operative shall have a lien on any equity I may have in the Co-operative, including all my shares and all funds arising from patronage refunds for all monies owing by me to the association, including all collection costs and legal fees.

The Co-operative reserves the right to register a security interest in all present and after acquired property of the account holder.

I consent to the exchange of account, credit, and personal information by the Co-operative with any credit grantor, credit bureau, credit reporting agency, or my employer, at any time.
DATED AT (LOCATION)*
DATED ON*

MonthDayYear
Date
APPLICANT'S SIGNATURE*

Clear
CO APPLICANT'S SIGNATURE

Clear

CO-OP Cardlock Cardholder Application
Name of Applicant
Address of Applicant
Applicant's Phone No
Dyed Fuel Permit(s) #
Prov.
Dyed Fuel Permit(s) #
Prov.
Email Address

Please read the following and sign.

1. I apply for a cardlock card(s) (the "Card") of the local or system-wide type, as indicated above, for the purchase of petroleum fuel in the CO-OP Cardlock System.

2. I agree to complete and sign the necessary account application form.

3. I hereby confirm that I have been provided a copy of the Cardlock User Agreement (Form 910) and, if my application herein is accepted, I unequivocally confirm that I accept all terms and conditions contained therein. In particular, I acknowledge that I have carefully read and reviewed paragraph 6 of the cardlock user agreement and fully and unequivocally confirm that I shall be fully responsible for all charges incurred as against my carlock card regardless of whether the charges were incurred without my consent or knowledge.

4. I will not purchase marked fuel in a province where I do not have a marked fuel purchasing permit. If such a purchase is made, I understand that I will be charged the clear fuel price (inclusive of all taxes I also understand that this may result in prosecution under the applicable provincial fuel tax act(s).

5. For Manitoba users of marked fuel: As the purchaser of marked fuel in the Province of Manitoba, I fully understand and agree that marked fuel must be purchased solely for the purposes authorized under The Fuel Tax Act and that any unauthorized use may result in prosecution.
SIGNING BY PERSONAL APPLICANT
Signature of Sole Proprietor

Clear
Date

MonthDayYear
Date
Signature of Witness

Clear
Name of Witness

First NameLast Name
Date

MonthDayYear
Date

CARDLOCK USER AGREEMENT
The following are the terms and conditions of the agreement between Federated Co-operatives Limited ("FCL"), the person (the "Customer") to whom the enclosed cardlock card(s) (the "Card") is issued and the retail co-operative (the "Co-op") from which the Customer received the Card. The use by the Customer of the Card indicates the Customer's acceptance of these terms and conditions.

1. Ownership of the Card at all times remains in the Co-op, and the Co-op, or its agent, may retake possession of the Card at any time on or after termination of this agreement. Upon termination of this agreement, the Customer must return the Card to the Co-op

2. The term of this agreement is one year commencing on the date the Card is first used by the Customer. This agreement will be automatically renewed for successive one-year terms subject to the various termination rights set out. The Customer may terminate this agreement by giving written notice of termination to the Co-op at any time. The Co-op may terminate this agreement at any time on 30 days written notice to the Customer.

3.If the Customer has more than one Card, the Customer is responsible for all purchases made using the cards provided.

4. The Customer may use the Card to obtain the petroleum products for which the Card is authorized from pumps (the "Pumps") in the CO-OP and TEMPO Cardlock network from time to time. The dispensing equipment is to be used by trained cardholders only, and is not open for the use of the general public.

5. The prices to be paid for petroleum products purchased through the Co-op's Pumps using the Card will be the prices established by the Co-op for the Customer. The Co-op prices may be changed by the Co-op from time to time.

6. The Customer agrees to pay for all petroleum products recorded by the Pumps to the Customer's account number until WRITTEN notice of loss of the Card is received by the Co-op. The Customer shall be fully and completely responsible for all such charges to the Card, regardless of how such charges have been incurred or by whom. Notice to the Co-op, as defined in this paragraph, shall only be effective, and thereby relieve customer of any liability for further charges, when such written notice is actually received by the Co-op.
INITIAL*

Clear
The customer confirms and agrees that they are fully and unequivocally responsible for the safe guarding of their PIN and assumes all and complete liability for its safe keeping and use with the cardlock card. The customer agrees that they must not disclose their security (PIN) number and are fully responsible for the security of it. In particular, the customer unequivocally covenants and agrees not to write the PIN on the card and shall assume full and complete responsibility for the security of both the Card and PIN.
INITIAL*

Clear
7. All accounts are due when rendered. Purchases of petroleum products from the Co-op are payable in full in accordance with the Co-op's credit terms. Purchases of petroleum products from FCL, other retail co-operatives and TEMPO dealers are payable in full each month. If the Customer fails to pay their account(s) within the credit terms, the Customer agrees to pay interest at the rate set from time to time by the Co-op or FCL, or both as the case may be, on the balance of the account(s) from the statement date upon which the invoice(s) appeared until payment is received by the Co-op or FCL, or both, as the case may be. By example if the Co-op's or FCL's interest rate for a 30 day account was 2% per month (24% per year) charged monthly it would have an effective rate of 26.8% per year. The Co-op or FCL, or both, as the case may be will advise the Customer of the actual interest rate and any changes in its interest rate as required by law. The Co-op may suspend or limit the right of the Customer to use the Card until payment has been received by the Co-op or FCL, or both, as the case may be. The Co-op has the right to terminate this agreement immediately and without notice to the Customer if any payment to the Co-op or FCL is not made when due. Payments which do not retire the account in full will be applied first to the interest and secondly to reduce the principal outstanding. If the Customer's account this FCL is past due, FCL will transfer the balance of the account to the Co-op. The Customer agrees to pay all costs and expenses incurred by the Co-op in the collection of any past due account including legal fees on a solicitor-and-client basis.

8. Co-op patronage will be paid only on petroleum products purchased at the Co-op's own cardlock and will be subject to the provisions of the Co-op's patronage policy.

9. The Co-op had the right at any time to change the access mechanism or codes at the Pump. If the Customer is in default under this agreement or becomes insolvent or bankrupt, the Co-op may terminate this agreement immediately.

10. Neither FCL nor the Co-op nor any retail co-operative nor any TEMPO dealer is liable to the Customer for any inability by the Customer to obtain petroleum products for any reason whatsoever.

11. All notices required to be sent by the Customer to the Co-op must be sent by any two of the following methods: phoning, by email, or by registered mail communication or by personal delivery all to the attention of the petroleum department of the Co-op. The Co-op may provide notices to the Customer by phone, email, or mail to the Customer's numbers or address as shown on their account application. The parties agree to notify each other of changed in their telephone number(s), email, and address.

12. If the Customer wishes to obtain additional or amended cards, they may make a verbal request to the Co-op, and, if issued, those additional or amended cards will be subject to the terms and conditions of this agreement even though they were not delivered with this agreement.

13. The Customer acknowledges that they have received instructions in (a) the means of activating dispensing equipment using the Card; (b) the proper operation of the dispensing equipment; and (c) the location and proper use of the emergency shut off switched and the fire extinguisher. The dispensing equipment at a cardlock is to be used by trained cardholders only, and is not open for use by the general public.

14. The Customer agrees that they and every person to whom the Customer gives a Card; (a) will not leave the dispensing equipment unattended at any time while it is being operated; (b) will control sources of ignition; and (c) will not dispense petroleum products into containers which do not comply with fire regulations.

15. The Customer agrees to indemnify FCL, and the owner of the site from which petroleum products are dispensed using the Card against all claims, liabilities, demands, damages and causes of action, and all costs and expenses of investigation and defending them including legal fees on a solicitor-and-client basis, arising from the use of the Card or the dispensing equipment, including injury to a person or persons, including death and property damage including environmental contamination of soil or groundwater.

16. The Co-op may vary the terms on which the Card is used at any time by notice to the Customer. Any use of the Card after notice of a change is subject to the varied terms.

FORM 910 (REV. Jan.'09)

ITEM 2808525
Printed Name*
Applicant Signature*

Clear
Date*

MonthDayYear
Date

Should be Empty:

Personal Credit Application

PERSONAL / NON-CORPORATE FARM CREDIT APPLICATION

*By providing your email you give Lake Country Co-op permission to use this address for communication.

SECTION B:

ACCOUNT NO

CREDIT POLICY

RETURNED CHEQUES

AGREEMENT

CO-OP Cardlock Cardholder Application

CARD SPECIFICATIONS REQUESTED:

SIGNING BY PERSONAL APPLICANT

CARDLOCK USER AGREEMENT