RLC Coop Fillable PDF Form

In order to establish credit with Red Lake County Cooperative Inc, 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 Red Lake County Cooperative Inc will only collect and use information needed to offer and fulfill its business purposes. Red Lake County Cooperative Inc will retain only what is needed to maintain its relationship with the individual/business. This means that Red Lake County Cooperative Inc will not disclose information for an unrelated purpose without the consent of the individual or by authority of law.

MUST CHOOSE ONE:

I/We would like to apply for credit terms with Red Lake County Cooperative Inc and receive a billing statement.I/We are choosing to be a cash customer with payment due prior to delivery with Red Lake County Cooperative IncI/We would like to apply for auto-pay checking/savings account customer with Red Lake County Cooperative IncI/We would like a local charge card for c-store purchases

Full Name*

Co-Applicant Name

Billing Address*

Billing Address

City/State/Zip*

City/State/Zip

Phone Number*

Phone Number

Work Number*

Please enter a valid phone number.

Work Number

Please enter a valid phone number.

SSN or Tax ID*

SSN or Tax ID

Date of Birth*

Date

Date of Birth

Date

Email Address

example@example.com

Service Address

City/State/Zip

Landlord Name

Landlord Phone Number

Business Reference

Business Reference Phone Number

How would you like to receive your statements?*

EmailPaper

What services would you be needing?*

PropaneFuel OilC-StoreAgronomy

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 Red Lake County Cooperative Inc 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 days, 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 or terminated. I further acknowledge that | have read, understand, and agree to the terms and conditions of credit listed in the Red Lake County Cooperative Inc credit policy.

Signature of Applicant*

Signature of CoApplicant

Date*

Date

Individual Consent and Certification of Taxpayer I.D. Number

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

Printed Name as Shown on Account*

Taxpayer ID EIN or Social Security Number*

Mailing Address*

Telephone Number*

City/State/Zip Code*

Date of Birth*

Date

I hereby consent to included in my gross income, as now hereafter provided in the federal income tax laws, the state dollar amount of each written notice of allocation which I receive from Red Lake County Cooperative Inc, Brooks, 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*

Date*

Date

Business Personal Guarantee

(To be completed by all business applicants)

Each of the undersigned hereby guarantees full payment of all present future indebtedness of the applicant. This guarantee is open and continuous and is given in induce Red Lake County Cooperative Inc, hereafter "The Cooperative" to extend credit to the applicant. This personal guarantee shall remain effective until evoked by the undersigned by notice in writing to The Cooperative. However, such a revocation shall be effective only as to amounts due which arise out of new contracts or transactions entered into more than 30 days after receipt of notice by The Cooperative. Such notice must be given by certified mail to The Cooperative. At any time, The Cooperative may, without notice, extend credit to applicant or modify, renew, extend, or compromise any indebtedness: take, subordinate or release any security interest; release applicant or any other guarantor from any liability for indebtedness and otherwise deal with applicant and other guarantors in any manner deemed fit, without waiving the effectiveness of this personal guaranty. Each guarantor waives presentment, demand, protest, and notice of any kind. If any guarantor, without first proceeding against the applicant, or any other person or security, and without pursuing any other remedy. In any proceeding to interpret or enforce this personal guaranty, The Cooperative shall be entitled to recover all of its costs and attorney fees from any personal guarantor. All notices regarding this personal guarantee must be sent to Red Lake County Cooperative Inc, PO Box 37, Brooks, MN 56715. Each guarantor hereby consents to the jurisdiction of the Court of the State of Minnesota, County of Red Lake, and the U.S. District for the District of Minnesota.

Guarantor Name and Title

Guarantor Social Security Number

Guarantor Signature

Date

Account Application