Personal Credit Application

First Name

M.I.

Last Name

S.S.N.

Mailing Address

City

State

Zip

Email Address

Select what you want via email

Date of Birth

Phone Number

Place of Employment

Years Employed

Employer Address

Employer City

Employer State

Employer Zip

Employer Phone Number

Co-applicant (optional)

First Name

Co-applicant M.I.

Co-applicant Last Name

Co-applicant S.S.N.

Co-applicant Phone

Co-applicant Date of Birth

PROPANE (optional)

Fill out the information below if you are interested in purchasing propane.

Propane Delivery Address

City

State

Zip

Property Ownership

Tank Ownership

Tank Size

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

Special Requests

CARDTROL CARD (optional)

Fill out the information below if you are interested in applying for a Cardtrol Card.

First Name

Middle Initial

Last Name

Phone Number

Mailing Address

City

Zip

State

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

Tank Wagon Diesel or Gas (optional)

Fill out the information below if you are interested in tank wagon gas and diesel.

Delivery Address

City

State

Zip

Product

Tank Size

Special Requests

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

Tell us if you're looking for something other than what we've listed.

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

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

Personal Credit Application

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