River Country CO-OP logo

Commercial Credit Application

1080 W River Street Chippewa Falls, WI 54729 - Phone: 723-2828 or 1-800-828-9395 Fax 715-723-4733

River Country CO-OP credit policy can be found at: http://ww3.rivercountrycoop.com/credit/#credit-policy


Applicant Name: (please include first and last name.)
Trade Name: Credit Line Request:
Delivery Address: City: State: Zip:
Billing Address (if different) : City: State: Zip:
Type of Business: Federal ID#:
State ID#: Years in Business:
Business Phone #:Business Fax #:
Applicant Cell Phone: E-mail Address:
TYPE OF ORGANIZATION
Corporation Partnership Limited Liability Partnership (LLP)
Limited Liability Company (LLC) Non-Profit Other:
PRIMARY OFFICERS, OWNERS, or PARTNERS
Name: Title: S.S.#:
Name: Title: S.S.#:
BANK ACCOUNT INFORMATION
Bank: Address:
Account #: Phone #: Contact Person:
CREDIT REFERENCES
Business: Address:
Phone #: fax #: Contact Person: Years Doing Business With:
Business: Address:
Phone #: fax #: Contact Person: Years Doing Business With:
Products & Services Needed
Diesel Gasoline L.P. Gas #1 Fuel Oil #2 Fuel Oil Agronomy Feed

NOTICE TO MARRIED APPLICANTS: No provision of any marital property agreement, unilateral statement under S.766.59 Wis Stats., or court degree under S.766.70 adversely affects the interest of the creditor unless the creditor, prior to the time the credit is extended or an open-end credit plan is entered into, is furnished a copy of the agreement, statement or decree or has actual knowledge of the adverse provision, when the obligation to the creditor is incurred. For Married Wisconsin Resident: If I am married, a Wisconsin resident, and applying for an individual account, I agree that credit extended under this account if granted, will be incurred in the interest of my marriage or family.

Terms: Purchases made during one month are due in full by the 23rd of the following month. Open End Credit Disclosure: Any charges not paid by the 23rd of the month following the month of purchase will be subject to a finance charge of 1.5% per month (18% Annual Percentage Rate) on unpaid balance.

I acknowledge that I have read and understand the preceding statement.

Please type your full name into following box. By entering your legal name in this box you will be electronically signing this form.