Belgrade Cooperative Business App 05/24

Business and/or Agronomy Applicants
Business Name
Sole ProprietorPartnershipCorporation
Mailing Address

Street Address Line 2

CityState/Zip

Zip
Email Address
example@example.com
Delivery Address
City / State
Zip
Federal ID Number
Date Business Started

MonthDayYear
Date
Person to Contact Regarding Financial Matters
Title
Phone Number
Please enter a valid phone number.
Credit References: List all obligations with banks, finance companies, private lenders, contracts for deeds, etc.
Has the applicant filed bankruptcy within the past seven years? If yes, please explain.

NOYES
Name of Bank
Address
Phone Number
Please enter a valid phone number.
Acct. Number
Type a question

NOYES
Name of Bank
Address
Phone Number
Please enter a valid phone number.
Acct. Number
Lender Name and Address
Phone Number
Please enter a valid phone number.
Balance
Payment
Lender Name and Address
Phone Number
Please enter a valid phone number.
Balance
Payment
Trade References: List suppliers of fert or chemicals, feed or animal health, petroleum or home heating, farm supplies or other credit references.
Name & Address of Trade Reference
Phone Number
Please enter a valid phone number.
Balance
Payment
Name & Address of Trade Reference
Phone Number
Please enter a valid phone number.
Balance
Payment
Has the applicant filed bankruptcy within the past seven years? If yes, provide date & 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(enclosed).

I certify that I am authorized to sign this agreement and to thereby bind the person(s) on whose behalf I am signing. Everything that I have stated in the application is correct to the best of my knowledge. I understand that Belgrade Co-op will retain this application whether or not it is approved. Belgrade Co-op is authorized to check my credit and employment history and I agree to answer questions about my credit experiences I voluntarily agree to have my credit history reviewed at any time.
Applicant's Signature

Clear
Date Signed

MonthDayYear
Date
Type a question

PropaneAgronomyBulk Fuel/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
Phone Number
Please enter a valid phone number.
City/ State/ Zip
Birth Date

MonthDayYear
Date
Signature

Clear
Date

MonthDayYear
Date
How did you hear about us? (Check all that apply)
Belgrade Co-op Employee

Website SearchFacebookBillboard/Tank signsNewspaper AdCoworker/FriendRadio AdOtherBelgrade Cooperative Employee
Should be Empty:

Business and/or Agronomy Applicants