BELGRADE COOPERATIVE RESIDENTIAL APPLICATION 11-24-25

BELGRADE COOPERATIVE

Residential Applicants
Last Name
First Name
Middle Name
Date of Birth

MonthDayYear
Date
Drivers License No
Address

Address

Street Address Line 2

CityState

Zip
Do you Rent or Own your home?

RENTOWN
Home Phone Number
Cell Phone Number
SSN
Email Address
example@example.com
Present Employer
Phone Number
Years There
Position
Individual Monthly Income
CO-APPLICANT(OPTIONAL)
Last Name
First Name
Middle Name
Date of Birth

MonthDayYear
Date
Drivers License No
Home Phone Number
Cell Phone Number
SSN
Email Address
example@example.com
Present Employer
Phone Number
Years There
Position
Individual Monthly Income
Has the applicant filed bankruptcy within the last 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

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Date

MonthDayYear
Date
Co-Applicants Signature

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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 ( form must be completed to be eligible for patronage dividends)
Name as shown on account
Taxpayer SSN or EIN
Mailing Address
City
State
Zip
Telephone Number
Birth Date

MonthDayYear
Date
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(s) Date
Signatures

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Date

MonthDayYear
How did you hear about us?
Type a question*

Website SearchFacebookNewspaper AdRadio AdBillboard/Tank SignsOther
If referred by someone, write the name below: Write N/A if not applicable*