Riverbend Individual Application

Riverbend Co-operative Ltd.
101 Saskatchewan Ave EastPO Box 69
Outlook, SK SOL 2NO

Administration: (306) 867-8614
admin@riverbendcoop.com

Riverbend Co-op Member Number (Your Tullis Co-op # with a '60' at the beginning)

Member Name

Address

Date of Birth MM/DD/YYYY

Date

Social Insurance Number

Cell Number

Email

example@example.com

I understand that all purchases made on my Riverbend Co-op account during a calendar month are payable in full by the last day of the following month. Any unpaid balance after that date will be subject to a service charge of 24% per annum (2.0% per month), calculated monthly and added to the account until it is paid in full or brought current within the agreed terms. I further agree to be responsible for any collection costs incurred in recovering any unpaid balance.

Payment of credit accounts may be made with cheque (payable to Riverbend Co-op), online banking (payee - Riverbend Co-op and use your co-op number as account number) or in person at any of our locations using debit. Payment by credit card is not permitted on charge accounts.

The issuance of a Riverbend Co-op credit account constitutes an agreement by Riverbend Co-op to extend credit to me under the above terms, subject to any amendments or arranged credit limits.

I accept responsibility for all goods and services charged to my account until I provide written notice to Riverbend Co-op.

I hereby apply for credit with Riverbend Co-op with a credit limit of $

I certify that the above information provided in this application is true and correct. I authorize Riverbend Co-op to obtain any

credit information it deems necessary from a credit reporting agency or from any person or organization with whom I have

or may have financial relations. I accept full responsibility for all purchases made on this account.

Signature

Date

Please verify that you are human*