BUSINESS CREDIT APPLICATION

Business Name

DBA (if different)

On Site Contact

Accounts Payable Contact

Mailing Address

City

State

Zip

Is your mailing address different than your billing address?

Billing Address

City

State

Zip

Email Address

Select if you want

EIN/Federal ID Number

Phone Number

Fax Number

Purchase Order Required?

Amount of Credit Requested

Date of Business Established

Business Type

State of Incorporation

First Executive Officer

Title

Address

City

State

Zip

Add Officer 2

Remove Officer 2

Second Executive Officer

Title

Address

City

State

Zip

Add Officer 3

Remove Officer 3

Third Executive Officer

Title

Address

City

State

Zip

First Partner Name

Address

City

State

Zip

Add another Partner Remove Partner

Second Partner Name

Address

City

State

Zip

Sole Proprietor/LLC Name

S.S.N.

Address

City

State

Zip

Trade References

Trade Reference 1

Reference Name

Address

City

State

Zip

Phone Number

Fax Number

Trade Reference 2

Reference Name

Address

City

State

Zip

Phone Number

Fax Number

Add Trade Reference 3

Remove Trade Reference 3

Trade Reference 3 (optional)

Reference Name

Address

City

State

Zip

Phone Number

Fax Number

Add Trade Reference 4

Remove Trade Reference 4

Trade Reference 4 (optional)

Reference Name

Address

City

State

Zip

Phone Number

Fax Number

Bank References

Bank Reference 1

Reference Name

Address

City

State

Zip

Phone Number

Fax Number

Add another Bank Reference Remove Bank Reference

Bank Reference 2 (optional)

Reference Name

Address

City

State

Zip

Phone Number

Fax Number

Commodity to be Purchased

Select commodities below. More than one may be selected. Once selected, the form will appear.

Propane

Cardtrol Card

Tank Wagon Gas/Diesel

Other

Please fill out the propane information below

Propane Delivery Address

City

State

Zip

Property Ownership

Landlord

Tank Ownership

Tank Size

Delivery Method Will deliver propane on route basis. Must have credit approved and remain current.

Special Requests Leak check could be done on new customer’s system at no charge.

Add Propane Tank 2

Remove Propane Tank 2

Please fill out the propane information below

Propane Delivery Address

City

State

Zip

Property Ownership

Landlord

Tank Ownership

Tank Size

Delivery Method Will deliver propane on route basis. Must have credit approved and remain current.

Special Requests Leak check could be done on new customer’s system at no charge.

Add Propane Tank 3

Remove Propane Tank 3

Please fill out the propane information below

Propane Delivery Address

City

State

Zip

Property Ownership

Landlord

Tank Ownership

Tank Size

Delivery Method Will deliver propane on route basis. Must have credit approved and remain current.

Special Requests Leak check could be done on new customer’s system at no charge.

Add Propane Tank 4

Remove Propane Tank 4

Please fill out the propane information below

Propane Delivery Address

City

State

Zip

Property Ownership

Landlord

Tank Ownership

Tank Size

Delivery Method Will deliver propane on route basis. Must have credit approved and remain current.

Special Requests Leak check could be done on new customer’s system at no charge.

I / We are interested in more information about propane contracts

Please fill out the Cardtrol Card application information below

Business Name

Phone Number

Mailing Address

City

State

Zip

Number of Cards

Pin Preference

Products

Limitations for Each Transaction

Prompt

Purchase more than 10,000 gal/yr

This agreement, made and entered by and between . Hereinafter referred to as “Customer” and W & H Cooperative Oil Company, hereinafter referred to as W & H.

Cardtrol Card(s) may be used to operate the fuel pumps at W & H locations in Humboldt, Fort Dodge, Eagle Grove, Renwick, Livermore, Badger, Clare, Vincent, and Goldfield.

1. Customer agrees to comply with the credit policy of W & H, which states that credit purchases are subject to a finance charge of 1.5% per month with a minimum charge of $.50 for any month in which a finance charge is imposed. No finance charge is imposed if the balance at the end of the month is paid by the 15th day of the following month and I hereby agree to pay any such charges assessed. No additional credit will be extended to past due accounts unless satisfactory arrangements are made with our credit department.

2. In the event of a lost or stolen card, Customer agrees to immediately notify W & H Office, which will then promptly render that card invalid. Until such date and hour as Customer has so notified W & H of a lost, stolen or misplaced card, Customer shall remain liable for all purchases recorded on the Customer’s statement. Upon notification of the loss or disappearance of any card, W & H agrees to issue the customer a new card with a new pin.

3. Customer agrees to not leave the dispensing equipment unattended at any time while it’s being operated and to accept the responsibility of controlling sources of ignition. The customer agrees to abide by all state fire regulations and also Environmental Protection Agency rulings while utilizing the Cardtrol System.

4. Customer may terminate this agreement at any time by returning all the cards to W & H with payment in full for their charge account.

5. Customer understands that the Pin number is a special 4-digit number which must be manually entered every time the customer purchases fuel. A pin is used for security. Please store your pin separately from your cardtrol card.

The undersigned hereby unconditionally guarantee(s) payment when due, and agrees to pay all expenses (including attorney’s fees and legal expenses incurred by W & H to collect the debt and enforcing this guarantee).

Signature

Date

Please fill out the tank wagon gas and diesel information below

Tank Wagon Refined Fuels

Delivery Address

City

State

Zip

Product

Tank Size

Special Requests

Add Tank Wagon Delivery Option 2

Remove Tank 2

Please fill out the tank wagon gas and diesel information below

Tank Wagon Delivery Information

Delivery Address

City

State

Zip

Product

Tank Size

Special Requests

Add Tank Wagon Delivery Option 3

Remove Tank 3

Please fill out the tank wagon gas and diesel information below

Tank Wagon Delivery Information

Delivery Address

City

State

Zip

Product

Tank Size

Special Requests

Add Tank Wagon Delivery Option 4

Remove Tank 4

Please fill out the tank wagon gas and diesel information below

Tank Wagon Delivery Information

Delivery Address

City

State

Zip

Product

Tank Size

Special Requests

I / We are interested in more information about spring/fall fuel contracts.

Please tell us what other commodity you are interested in purchasing

Please tell us what you are looking for!

Acknowledgements and Agreements

I represent that the above information is true and is given to induce W & H Cooperative Oil Company to extend credit to the applicant. My company and I hereby authorize W & H Cooperative Oil Company or any credit bureau or other investigative agency employed by W & H Cooperative Oil Company to investigate any reference herein listed or statements or other data obtained from me or from any person pertaining to the company’s credit and financial responsibility. I UNDERSTAND AND AGREE THAT CREDIT PURCHASES ARE SUBJECT TO A FINANCE CHARGE OF 1.5% PER MONTH, WITH A MINIMUM MONTHLY CHARGE OF $.50 FOR ANY MONTH IN WHICH A FINANCE CHARGE IS IMPOSED. NO FINANCE CHARGE IS IMPOSED IF THE BALANCE AT THE END OF THE MONTH IS PAID BY THE 15TH DAY OF THE FOLLOWING MONTH, AND I HEREBY AGREE TO PAY ANY SUCH CHARGES ASSESSED. No additional credit will be extended to past due accounts unless satisfactory arrangements are made with our credit department. The undersigned agrees to pay for all costs, attorney fees, and other expenses that W & H Cooperative expends or incurs in the collection of any indebtedness for credit extended under this credit application.

Signature

Date

PERSONAL GUARANTY

The undersigned unconditionally guarantees to W & H Cooperative Oil Company the prompt payment when due of all obligations under this account. The undersigned agrees to pay all attorney’s fees and other expenses incurred by W & H Cooperative Oil Company by reason of default. It is understood that this guaranty shall be a continuous and irrevocable guaranty and indemnity for such indebtedness. This guaranty shall bind the heirs, administrators, successors and assigns of the undersigned and may be enforced by or for the benefit of any assignee or successor of W & H Cooperative Oil Company. This guarantee extends to all principal, interest, costs, fees, attorney fees, and expenses incurred upon or by virtue of the extension of credit hereunder.

Guarantor Signature

Date

If this application is approved, I would like a membership with W & H Cooperative Oil Company.

I/We the undersigned, being eligible for membership in the W & H Cooperative Oil Company of Humboldt, Iowa, hereby apply for membership which, upon acceptance, will be acknowledged and duly recorded by the issuance of a certificate for one share of common stock at a total purchase price of $10.00.

I/We the undersigned agree to the following:

The undersigned has received a copy of the articles of the association.

The undersigned may review the most recent annual report of the association at the corporate office in Humboldt.

The undersigned agrees to take any applicable patronage refunds into taxable income in the taxable year in which such written notices of allocation are received, in accordance with the by-laws of the association.

The undersigned is a person who customarily uses the supplies, commodities, or services of the association.

Checks for the $10.00 membership fee can be made out to W & H Cooperative and mailed to PO Box 528 Humboldt IA 50548 OR can be paid over the phone with a card at 515-332-2782

The membership of the association is not transferable, except for repurchase by the association.

This application is subject to acceptance by the association and shall be fully effective and irrevocable upon acceptance by the board of directors or the association without written notice by the secretary to the undersigned.

Check for Acknowledgement

Signature

Date

Are you engaged in farming?

Please issue membership as follows

Business Name

EIN/Federal ID Number

Mailing Address

City

State

Zip

Business Type

W-9 Information

Visit IRS.gov to Fill out a W-9 and upload it below:

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