Credit Application

In order to establish credit with Northern Star Cooperative Services, the information requested below must be provided in its entirety. Please take a few minutes to complete this form. We cannot begin service until this and all required forms are returned to our office.

Privacy Disclosure: Individual privacy is very important, so Northern Star Cooperative Services will only collect and use information needed to offer and fulfill its business purposes. Northern Star Cooperative will retain only what is needed to maintain its relationship with the individual. This means Northern Star Cooperative will not disclose information for an unrelated purpose without the consent of the individual or by authority of law.

MUST CHOOSE ONE*

I/We are choosing to be a C.O.D./cash customer (Payment Due Prior to Delivery) with Northern Star Cooperative.I/We would like to apply for credit terms with Northern Star Cooperative.I/We would like to apply as an autopay credit card account customer with Northern Star Cooperative.

Full Name*

Co-Applicant Name

Address*

Billing Address

Street Address Line 2

City/State/Zip

Address

Billing Address

Street Address Line 2

City/State/Zip

Phone Number*

Phone Number

SSN or Tax ID*

SSN or Tax ID

Date of Birth*

Date

Date of Birth

Date

Email Address

example@example.com

Email Address

example@example.com

How would you like to receive your statements?*

EmailPaper

Property Purchased From

Service Address

Landlord Name

City/State/Zip

Landlord Phone Number

This residence uses:

PropaneFuel OilC-Store/Market Place

I/We give this information for the purpose of obtaining credit and certify that the above information is true and correct. Authorization is hereby given to check credit. If approved, I/we agree to make payments to Northern Star Cooperative Services according to their terms. No further delivery or service will be provided until the previous balance is paid in full. It is further agreed that a late payment charge on the unpaid balance will be applied on accounts not paid within 30 day, and I/we will pay any and all costs to collect on the account including, but not limited to, the attorney fees. It is understood that delinquent account(s) will have their credit suspended. I further acknowledge that I have read, understand, and agree to the terms and conditions of credit listed in the Northern Star Cooperative Credit Policy.

Signature of Applicant*

Clear

Signature of Co-Applicant

Clear

Date*

Date

Individual Consent and Certification of Taxpayer I.D. Number

(This form must be completed to be eligible for patronage dividends)

Full Name*

Taxpayer ID, EIN or SSN*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Telephone Number

Date of Birth*

Date

I hereby consent to included 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 I receive from Northern Star Cooperative Services, Deer River, MN 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 as long as the revocation is provided in writing.

Certification – Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer I.D. 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 notified by the IRS that I 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 underreported 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*

Date

The Federal Truth in Lending Act requires all businesses, including your NORTHERN STAR COOPERATIVE SERVICES, to disclose credit terms to the customers in a uniform manner. Your Board of Directors have adopted the following credit policy.

A. Purchases will be billed monthly. B. Billing cycle closing date is the end of each month. C. Itemized statement will be mailed or emailed. D. Payment in full is due by the last day of the month following the month that the item was purchased in. E. If account is not paid in full by the due date, the past due amount will be assessed 1.5% per month finance charges (18% A.P.R F. If the balance becomes 60 days past due, your charging privileges may be withdrawn unless arrangements are made with our credit manager.

A. Minimum delivery for LP gas is 200 gallons. Orders of less than 200 gallons of LP gas and who are not on scheduled delivery, will be charged 30 cents a gallon more than the regular price. B. Accounts that are not authorized to charge must make payment in one of our offices prior to delivery. Our office hours are Monday through Friday, 8:00 A.M. through 4:30 P.M. C. Delivery and mileage charges will be applied for same day, weekend or holiday deliveries.

A. Can be used for gas, fuel and C Store purchases. B. Patron applies, if approved, card is given C. Credit terms are the same as open account. D. No fee-Safety features if lost.

VI. ACCOUNTS PAST DUE (PROCEDURE)

III.CENEX CONVENIENCE CREDIT CARD

A. Application must be approved by Cenex Corporation. B. Card and instructions issued by Cenex. C. Monthly billing from Cenex, not Northern Star Co-op. D. If total is $450.00 or greater, Cenex authorization is required. E. No fee-We also accept Visa, Mastercard, Discover, American Express, Diners Club.

A. Patron will receive a phone call. B. If no response, Patron will receive a "Reminder Letter". C. If no payment or arrangements have been made, charging privileges will be withdrawn and a "Final Letter" will be sent. D. All costs of court collection will be added to the delinquent account balance. D. To prevent this let us know if there is a problem. We want to work with you. Main office (218) 246-8296

A.This plan is available for heating accounts. Offering a fixed monthly payment. Payment is based upon your estimated annual usage. Open enrollment is June 1st thru September 1st.

A. $30.00 service charge will be assessed on each NSF check. B. We will pursue legal action through sheriff's office. C. If we must, we will pursue a legal remedy through the court and collection systems.

Our credit policy is a benefit and convenience to our qualified patrons. The policy applies to all patrons, employees, and the Board of Directors. We thank you for your business and support. If you ever have any questions, comments or concerns, please let us know.

Respectfully, Board of Directors, Northern Star Cooperative Services

Northern Star Cooperative Services

DISCLOSURE NOTICE

CREDIT POLICY AN APPROVED CREDIT APPLICATION

MUST BE ON FILE FIRST