River Country Co-op Credit Application

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


First Name: Middle Initial: Last Name:
Applicant Marital Status Married | Single Number of Dependants: (Do Not Include Yourself)

(If Applicable)

Co-Applicant / Spouse name:
Relationship to Applicant:
Address: City: State: Zip:
How long at present address: Own | Rent Home Phone: Fax:
E-mail Address: Cell Phone:

(If less than two years at present address)

Previous Address:
Landlord's Name: Phone:
Nearest relative not living with you:
Address Phone:
Credit Information
Applicant No. 1 Applicant No. 2
Date of Birth: Date of Birth:
Social Security #: No dashes E.G 111111111 Social Security #: No dashes E.G 111111111
Employer: Employer:
Job Title | Position Held: Job Title | Position Held:
Monthly Gross Income: Monthly Gross Income:
Employment Length: Employment Length:
Work Phone: Work Phone:
Yes, I am an agricultural producer.
Products & Services Needed
Diesel Gasoline L.P. Gas Fuel Oil #1 Fuel Oil #2 Agronomy Feed

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. When two payments are missed within 12 month period. Notice of default sent and time frame in place to resolve. In the event the Co-op initiates collection proceedings to collect amounts due on open account, all costs of collection and reasonable attorneys' fees incurred or paid by the Co-op in order to collect the amount due shall be added to the amount due and paid by Customer unless prohibited by law. This agreement applies to all unpaid charges incurred prior to the date of this agreement and all future charges. Everything that 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. By signing this application you are also guaranteeing any business debts to River Country Co-op will be covered.

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.