Co-Op Application Form

Co-Op Application

Please provide your information below.
Co-op Discounts

For qualifying co-ops we will offer the following discount schedule:

10 + students enrolled (discount based on total of the order)

$301 - $600 = 30%
$601 - $2000 = 35%
$2001 + = 40%

This must be on one order, paid and shipped to one address.

Excludes: Live Classes, Self-Paced Courses, AutoGrade+, digital products, lab items and free shipping.
Co-Op Information
Organization / Co-Op Name*
Main Contact Name
Main Contact's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Main Contact's Email Address
example@example.com
Years in Operation*
YesNo
Church Name*
Church Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Pastor's Name*
Pastor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
How many students do you have enrolled or do you plan to have enrolled?*
What grade levels does your Co-Op have? *
When do you expect your school year to begin? *
How many days a week do you meet?*
YesNo
SchoolChurchHomeOther
YesNo
Please upload a copy of your exemption certificate below.

Cancelof
YesNo
Billing and Shipping Information
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Delivery Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
ResidentialCommercial
Years at this address*
Accounts Payable Information
Accounts Payable Contact Name*

First NameLast Name
Accounts Payable Phone Number*
Format: (000) 000-0000.
Accounts Payable Email Address*
example@example.com
Payment
I would like to prepay.I would like to apply for a line of credit with Apologia Educational Ministries, Inc.
Credit Reference #1
Credit Reference #1 Name*
Credit Reference #1 Account Number*
Credit Reference #1 Balance Owed*
Credit Reference #1 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Credit Reference #1 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Credit Reference #2
Credit Reference #2 Name
Credit Reference #2 Account Number
Credit Reference #2 Balance Owed
Credit Reference #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Credit Reference #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Credit Reference #3
Credit Reference #3 Name
Credit Reference #3 Account Number
Credit Reference #3 Balance Owed
Credit Reference #3 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Credit Reference #3 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
The above references may accept copies of this application as authorization to release credit or financial information on my account. I certify that all the information on this form is correct. If credit is granted, I understand that invoices are due and payable in full within 60 days of invoice date (any extension of terms must be approved in writing). I agree to pay all invoices promptly when due. I understand that all past-due balances will be assessed a late payment charge of 2% per month, or $10, whichever is greater, and that becoming delinquent will affect credit privileges. In the event payment is not made and my account is referred for collection, I will pay all costs of collection. Apologia Educational Ministries, Inc. is authorized to make all inquiries deemed necessary to determine credit worthiness of the undersigned, and the undersigned hereby authorizes all persons of whom you make such inquiries to respond thereto in full. I further understand that the information provided may be used to obtain a consumer credit report. I agree to all the terms and conditions of sale as defined in the Apologia Educational Ministries, Inc. school policy information.

I authorize the above creditors to release credit information for the purpose of establishing an account with Apologia Educational Ministries, Inc.
Full Name

First NameLast Name
Signature

Clear
Should be Empty:

Co-Op Application

Co-op Discounts

Co-Op Information

Billing and Shipping Information

Accounts Payable Information

Payment

Credit Reference #1

Credit Reference #2

Credit Reference #3