BELGRADE COOPERATIVE BUSINESS/AGRONOMY APPLICATION 2025

BELGRADE COOPERATIVE

Business and/or Agronomy Applicants
Business Name
Type a question

Sole ProprietorPartnershipCorporation
Address

Mailing Address

Street Address Line 2

CityState

Zip
Email Address
example@example.com
Address

Delivery Address

Street Address Line 2

CityState

Zip
Person to Contact Regarding Financial Matters
Title
Phone Number
Please enter a valid phone number.
Date Business Started

MonthDayYear
Date
Federal ID No
Credit References: List all obligations with banks, finance companies, private lenders, contracts for deeds, etc.
Checking

NOYES
Name of Bank
Address
Phone Number
Acct Number
Savings

NOYES
Name of Bank
Address
Phone Number
Acct Number
Lender Name And Address
Phone Number
Balance
Payment
Trade References: List suppliers of fertilizer or chemicals, feed or animal health, petrolum or home heating, farm supplies or other credit references.
Name and Address of Trade Reference
Phone Number
Balance
Payment
Has the applicant filed bankruptcy within the past seven years?

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.
Applicants Signature

Clear
Date

MonthDayYear
Date
Which commodities do you plan to purchase (check all that apply):
Type a question

PropaneAgronomyBulk Fuel/GasC-store Fuel/Gas
Amount of Credit Anticipated to be needed
Individual Consent and Certification of Taxpayer I.D. Number (this portion must be completed to be eligible ofr patronage dividends)
Name as shown on account
Taxpayer SSN or EIN
Birth Date

MonthDayYear
Date
Telephone Number
Mailing Address
City
State
Zip
I hereby consent to include 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 Belgrade Co-op. 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 in writing. Certification - Under penalties of perjury, I certify that (1) The number shown on this form is my correct taxpayer ID 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.
Signature

Clear
Date

MonthDayYear
Date
How did you hear about us?
Website SearchFacebookNewspaper AdRadio AdBillboard/Tank SignsOther
If referred by someone, write the name below: Write N/A if not applicable. *
*Let us know who referred you to Belgrade Cooperative to earn a $25 credit to their account
Should be Empty: