Customer Account Information
* All fields with a red asterisk are required
24 Hr. Gas / Diesel Card for your vehicle at 8 locations: Blue River, Boscobel, Darlington, Dodgeville, Fennimore, Gays Mills, Lancaster and Patch Grove.
Individual Account Information
** Required - Either your Social Security Number OR Federal ID Number is required to submit this application.
Notice for married Wisconsin residents:
Wisconsin law provides that no agreement, unilateral statement or court decree relating to marital property shall adversely affect a creditor’s interest, unless prior to the time credit is granted the creditor is furnished a copy of the agreement, statement or decree, or has actually knowledge of the adverse provision. You must indicate the name of your spouse in the co-applicant/spouse section of this application.
Everything I have stated in this application is correct to the best of my knowledge. I understand that you will retain this application whether or not it is approved. You are authorized to check my credit and employment history and to answer questions about your credit experience with me. I also reaffirm the consent relative to allocation of patronage refunds for tax purposes. I give New Horizons Supply Cooperative permission to request and receive financial information on my accounts and accept the terms of the credit agreement and disclosure notice on page two.
Business / Commercial Account Information
Primary Officers, Members or Partners (please list)Note: At least one primary officer is required.
The undersigned agree to personally be responsible, jointly and/severally, for debts of the above corporation in favor of New Horizons Supply Cooperative which may accrue including any attorney's fees or other cost in the collection of this account as allowed by law. This shall be an open and continuing guaranty and shall be in force notwithstanding any change in the form of such indebtedness or renewals of extensions granted by New Horizons Supply Cooperative.
The Federal Truth in Lending Act requires prompt correction of billing mistakes.
The undersigned does hereby consent to take any qualified written notices of allocations of patronage refunds issued by New Horizons Supply Cooperative with respect to all patronage of the undersigned distributee with the association occurring during the current and all subsequent taxable years of the association, into account at their stated dollar amounts, for income tax purposes, in the year in which any such qualified written notices of allocations are received by the undersigned.
If your purchases from New Horizons Supply Cooperative are only personal items for you and your family, you do not have to include your refund in your reported income.
But, if you are a farmer or business person who purchases goods and services from New Horizons Supply Cooperative used to operate your farm or business, and if you have taken these purchases as a business expense on your tax return, then you need to include the cooperative refund as income.