Credit Application
Credit Application
Michiana Agra
Your Representative’s Name
For Office Use Only: Approved Cash Only Prepay Declined
Department Number
Thank you for your interest in Michiana Agra products and services. Your information will be treated in a confidential manner. Please print clearly and answer completely.
GENERAL PERSONAL DATA FOR ALL APPLICANTS NAME (LAST, FIRST, MIDDLE)
DATE OF BIRTH
PRESENT ADDRESS
CITY
HOW LONG AT THE ABOVE ADDRESS?
TELEPHONE:
SOCIAL SECURITY # ST
ZIP
MOBILE PHONE:
PREVIOUS ADDRESS (IF LESS THAN 3 YRS AT CURRENT) EMPLOYER
HOW LONG?
EMPLOYER ADDRESS
ST
TAKE HOME PAY $
CITY
PER
OCCUPATION?
ZIP
PHONE
OTHER INCOME SOURCES: (OPTIONAL)
PREVIOUS EMPLOYER (IF LESS THAN 3 YRS AT CURRENT) ADDRESS
CO–APPLICANT DATA
(if applicable)
CO–APPLICANT NAME
DATE OF BIRTH
SOCIAL SECURITY #
CO–APPLICANT EMPLOYER
HOW LONG?
EMPLOYER ADDRESS
ST
TAKE HOME PAY $
CREDIT REFERENCES NAME OF CREDITORS
CITY
PER
ZIP
PHONE
OTHER INCOME SOURCES: (OPTIONAL)
(minimum three-- complete with personal or corporation data as applicable) TYPE OF ACCOUNT/DEBT
LINE OF CREDIT/LIMIT
OTHER OBLIGATIONS (ALIMONY/CHILD SUPPORT/OTHER):
BANK REFERENCES
OCCUPATION?
PHONE/FAX REQUIRED
CURRENT BALANCE
$ AMOUNT
(complete with personal or corporation data as applicable)
NAME OF INSTITUTION
ADDRESS
PHONE
ACCOUNT NUMBERS AND NAMES ON ACCOUNT
IMPORTANT: HAVE YOU DECLARED BANKRUPTCY IN THE LAST 10 YEARS?
YES
ARE THERE ANY GARNISHMENTS OR JUDGMENTS PRESENTLY LEVIED AGAINST YOU?
NO
IF YES, WHERE?
YES
NO
EXPLAIN:
continued on back side
IF APPLYING AS A BUSINESS/CORPORATION:
* complete credit/bank reference sections on front as a business/corporation
CORPORATION NAME:
PARENT COMPANY?
PRINCIPAL OWNERS/PARTNERS BY NAME –– TITLE –– SOCIAL SECURITY NUMBER:
WHO IS AUTHORIZED TO USE/ORDER FOR THIS ACCOUNT? WILL A PURCHASE ORDER BE REQUIRED?
YES
NO
CORPORATION MAILING ADDRESS
LINE OF CREDIT REQUESTED?
NAME OF ACCOUNTS PAYABLE MANAGER? CITY
ST
ZIP
PHONE
PREVIOUS ADDRESS (IF LESS THAN 3 YRS AT CURRENT) YEARS IN OPERATION?
TAX EXEMPT NUMBER?
FEDERAL ID NUMBER?
Please be advised, you may be asked to submit a recent financial statement in the name of this corporation.
CUSTOMER HISTORY
Do you currently patronize this company?
Yes
No
Accounts under what name(s)/numbers(s)?
The applicant has delivered this statement to creditor to induce creditor to extend credit to the applicant. Everything that I have stated in this application is correct to the best of my knowledge. The applicant understands that the creditor will rely on the truth, accuracy and completeness of this statement. This applicant certifies that the information inserted herein has been carefully read and is true, correct and complete. I/We agree to pay the balance due and in addition all applicable FINANCE CHARGES which I/we hereby agree to pay in accordance to all terms and conditions in which I/we are notified from time to time, including but not limited to periodic statements sent to me setting forth the outstanding obligations I/we have to you. In the event judicial proceedings are commenced to collect sums owed on their account, all parties agree that such proceedings shall be venued in Hendricks County, Indiana, and all parties hereby consent to jurisdiction of the Courts of Hendricks County, Indiana. I/We hereby agree to pay all attorney fees and court costs if this account is referred to attorneys for collection, without relief from valuation and appraisement laws.In accordance with Article 9 Section 402 of the UCC Code, the buyer further grants to seller a security interest in buyer’s equipment, contract rights, inventories, receivables and proceeds of sales as collateral to secure the buyer’s performance of all obligations. The buyer further authorizes the seller to file a financing statement without buyer’s signature. A Finance Charge may be imposed if the unpaid balance shown on the current statement as the New Balance is not paid before the due date. If a Finance Charge is added, it is computed on the Average Daily Balance noted on the face of this statement at a periodic rate of 1.75% per month, which is an annual percentage rate of 21% or the highest prevailing rate provided by law. SEE ACCOMPANYING STATEMENTS FOR IMPORTANT DATA. THE TERMS OF SAID STATEMENT ARE INCORPORATED BY REFEREE HEREIN AND MADE A PART HEREOF. FOR CONSIDERATION, RETURN THIS FORM TO YOUR MICHIANA AGRA REPRESENTATIVE, OR MAIL TO: MICHIANA AGRA CREDIT SERVICES, 15115 STEARS ROAD, CONSTANTINE, MI 49042. Questions? Call (269) 435-2615.
Applicant Signature
Applicant Signature
Date
Date
By signing, I authorize Co-Alliance LLP (co-owner of Michiana Agra) to investigate my credit record and report to proper persons and bureaus my performance of this agreement and to answer any questions about their credit experience with me.
11-08 500 PIP
Michiana Agra
Michiana Agra
Your Representative’s Name
For Office Use Only: Approved Cash Only Prepay Declined
Department Number
Thank you for your interest in Michiana Agra products and services. Your information will be treated in a confidential manner. Please print clearly and answer completely.
GENERAL PERSONAL DATA FOR ALL APPLICANTS NAME (LAST, FIRST, MIDDLE)
DATE OF BIRTH
PRESENT ADDRESS
CITY
HOW LONG AT THE ABOVE ADDRESS?
TELEPHONE:
SOCIAL SECURITY # ST
ZIP
MOBILE PHONE:
PREVIOUS ADDRESS (IF LESS THAN 3 YRS AT CURRENT) EMPLOYER
HOW LONG?
EMPLOYER ADDRESS
ST
TAKE HOME PAY $
CITY
PER
OCCUPATION?
ZIP
PHONE
OTHER INCOME SOURCES: (OPTIONAL)
PREVIOUS EMPLOYER (IF LESS THAN 3 YRS AT CURRENT) ADDRESS
CO–APPLICANT DATA
(if applicable)
CO–APPLICANT NAME
DATE OF BIRTH
SOCIAL SECURITY #
CO–APPLICANT EMPLOYER
HOW LONG?
EMPLOYER ADDRESS
ST
TAKE HOME PAY $
CREDIT REFERENCES NAME OF CREDITORS
CITY
PER
ZIP
PHONE
OTHER INCOME SOURCES: (OPTIONAL)
(minimum three-- complete with personal or corporation data as applicable) TYPE OF ACCOUNT/DEBT
LINE OF CREDIT/LIMIT
OTHER OBLIGATIONS (ALIMONY/CHILD SUPPORT/OTHER):
BANK REFERENCES
OCCUPATION?
PHONE/FAX REQUIRED
CURRENT BALANCE
$ AMOUNT
(complete with personal or corporation data as applicable)
NAME OF INSTITUTION
ADDRESS
PHONE
ACCOUNT NUMBERS AND NAMES ON ACCOUNT
IMPORTANT: HAVE YOU DECLARED BANKRUPTCY IN THE LAST 10 YEARS?
YES
ARE THERE ANY GARNISHMENTS OR JUDGMENTS PRESENTLY LEVIED AGAINST YOU?
NO
IF YES, WHERE?
YES
NO
EXPLAIN:
continued on back side
IF APPLYING AS A BUSINESS/CORPORATION:
* complete credit/bank reference sections on front as a business/corporation
CORPORATION NAME:
PARENT COMPANY?
PRINCIPAL OWNERS/PARTNERS BY NAME –– TITLE –– SOCIAL SECURITY NUMBER:
WHO IS AUTHORIZED TO USE/ORDER FOR THIS ACCOUNT? WILL A PURCHASE ORDER BE REQUIRED?
YES
NO
CORPORATION MAILING ADDRESS
LINE OF CREDIT REQUESTED?
NAME OF ACCOUNTS PAYABLE MANAGER? CITY
ST
ZIP
PHONE
PREVIOUS ADDRESS (IF LESS THAN 3 YRS AT CURRENT) YEARS IN OPERATION?
TAX EXEMPT NUMBER?
FEDERAL ID NUMBER?
Please be advised, you may be asked to submit a recent financial statement in the name of this corporation.
CUSTOMER HISTORY
Do you currently patronize this company?
Yes
No
Accounts under what name(s)/numbers(s)?
The applicant has delivered this statement to creditor to induce creditor to extend credit to the applicant. Everything that I have stated in this application is correct to the best of my knowledge. The applicant understands that the creditor will rely on the truth, accuracy and completeness of this statement. This applicant certifies that the information inserted herein has been carefully read and is true, correct and complete. I/We agree to pay the balance due and in addition all applicable FINANCE CHARGES which I/we hereby agree to pay in accordance to all terms and conditions in which I/we are notified from time to time, including but not limited to periodic statements sent to me setting forth the outstanding obligations I/we have to you. In the event judicial proceedings are commenced to collect sums owed on their account, all parties agree that such proceedings shall be venued in Hendricks County, Indiana, and all parties hereby consent to jurisdiction of the Courts of Hendricks County, Indiana. I/We hereby agree to pay all attorney fees and court costs if this account is referred to attorneys for collection, without relief from valuation and appraisement laws.In accordance with Article 9 Section 402 of the UCC Code, the buyer further grants to seller a security interest in buyer’s equipment, contract rights, inventories, receivables and proceeds of sales as collateral to secure the buyer’s performance of all obligations. The buyer further authorizes the seller to file a financing statement without buyer’s signature. A Finance Charge may be imposed if the unpaid balance shown on the current statement as the New Balance is not paid before the due date. If a Finance Charge is added, it is computed on the Average Daily Balance noted on the face of this statement at a periodic rate of 1.75% per month, which is an annual percentage rate of 21% or the highest prevailing rate provided by law. SEE ACCOMPANYING STATEMENTS FOR IMPORTANT DATA. THE TERMS OF SAID STATEMENT ARE INCORPORATED BY REFEREE HEREIN AND MADE A PART HEREOF. FOR CONSIDERATION, RETURN THIS FORM TO YOUR MICHIANA AGRA REPRESENTATIVE, OR MAIL TO: MICHIANA AGRA CREDIT SERVICES, 15115 STEARS ROAD, CONSTANTINE, MI 49042. Questions? Call (269) 435-2615.
Applicant Signature
Applicant Signature
Date
Date
By signing, I authorize Co-Alliance LLP (co-owner of Michiana Agra) to investigate my credit record and report to proper persons and bureaus my performance of this agreement and to answer any questions about their credit experience with me.
11-08 500 PIP
Michiana Agra
