Commercial/Farm Use Application

This form is to be completed by any registered corporate entity such as a corporation, partnership or farm operating as a corporation.

Step 1 of 4: General Information

Business

Legal Business Name*

Doing Business As:Type of BusinessCorporation
Partnership
Sole Proprietorship
Business Registration No

Telephone Number*Fax NumberMobile Number

E-mail*

Mailing Address (If applicable include your 911 address)*

City/Town*ProvincePostal Code*

Is service to be provided to a different address from above?YesNo*

Step3 of 4: Bank & Credit Information

Banking Information

Bank*How long at this branch?

Full Address*Telephone Number

Account NumberAccount Manager

Credit

Credit Supplier/Reference

Name*

Address*

Name of Contact

Telephone Number*Fax Number

Credit Supplier/Reference

Name

Address

Name of Contact

Telephone NumberFax Number

Step 4 of 4: Terms & Authorization

Amount of Credit Request

$

If requesting a credit limit over $25,000 further information may be required.

Other Comments and Information

Terms & Conditions

1. The undersigned applicants and/or co-applicants (the “Applicants”) consent to:

a) the collection, use, disclosure and retention of personal information for purposes of enabling Hensall District Co-operative Inc. (HDC) to assess the credit-worthiness of the Applicants and in order to collect or enforce payment of any amount owing by the Applicants to HDC;

b) the obtaining of credit and/or personal information as may be required at any time in connection with the credit hereby applied for (the “Credit Facility”), any renewal or extension of such Credit Facility or the collection or enforcement of payment of any amounts owing to HDC; and

c)the disclosure of any credit information concerning the Applicants to any credit reporting agency or to any persons with whom the Applicants have or propose to have financial relations.

The Applicants may withdraw consent to the collection, use, retention and disclosure of personal information as described above by giving HDC reasonable written notice. The withdrawal of consent still allows HDC to use and disclose personal information to collect or enforce payment of amounts owing as a result of prior or continuing dealings with HDC. HDC confirms that the personal information described above will not be used or disclosed for any other purposes without the Applicants’ written consent to do so and further confirms that upon payment of any amounts owing to HDC that HDC will destroy any personal information it has collected in connection with this matter.

2. The Applicants acknowledge that the above information is for the purpose of obtaining credit from HDC and is warranted to be true and affirms that any credit given to the Applicants is extended on the basis of the information that has been provided. The Applicants authorize HDC to investigate the references listed above and to contact a credit bureau and/or any other sources pertaining to the Applicants’ credit and financial responsibility. HDC is also authorized to disclose the above credit information to other credit grantor’s or credit reporting agencies.

3. The Applicants agree to pay all sums due on or before the 20th day of the month following purchase. If payment is not made on or before the 20th day of the month following purchase interest will be charged commencing on the 21st day of the month following purchase on the outstanding balance owing at a rate of 2.5% per month (30% per annum).

4. HDC may, upon one month’s prior written notice to the Applicants, amend or vary the terms of the Credit Facility with the Applicants and the continued use of the Credit Facility by the Applicants following notification that the terms of the Credit Facility have been varied or amended will be deemed acceptance by the Applicants of the varied or amended terms as of the effective date mentioned in the notice, both with respect to indebtedness incurred subsequent to such date and unpaid indebtedness at such date.

5. The Applicants are jointly and severally liable for all indebtedness regardless of which applicant takes delivery of the goods and service. Credit limits may be increased/decreased at the sole discretion of HDC and in all cases the Applicants signing this agreement are jointly responsible for payment of all sums owed by either applicant regardless of initial credit requirement or limit. The creditor shall have the right, from time to time, to set off any amounts owing by the creditor to the applicant(s) against any amounts owing by the applicant(s) to the creditor.

6. The Applicants agree that any payments are to be applied firstly on account of unpaid interest charges and secondly on account of the purchase price of goods/service.

7. The Applicants, hereby agree that in the event of default in any term or terms of the Credit Facility that any and all costs incurred by HDC relating to the enforcement of the Credit Facility or the recovery of monies owed under the Credit Facility shall be considered as part of the principal debt owing, bear interest at the rate of 2.5% per month (30% per annum) and shall include without limitation any collection agency fees and legal costs on a substantial indemnity basis.

8. A photocopy, facsimile or electronic copy of this application will be considered a valid document in case of dispute.

9. Any payment returned NSF will result in an additional charge by way of an administration fee in the amount of $25.00 (subject to increase).

10. All decisions with respect to the extension, continuation or termination of the Credit Facility shall be at the sole discretion of HDC, and nothing herein shall obligate HDC to extend or continue to extend credit to the Applicants.

11. The Applicants will provide HDC any financial information requested by HDC including but not limited to updated financial information and a revised account application, as conditions for the continued extension of credit.

12. The Applicants hereby authorize any persons the Applicants deal with to release credit information relating to the Applicants to HDC.

13. If there is only (1) Applicant, the terms and conditions hereof shall be deemed to be amended to reflect the appropriate grammatical changes.

I agree to the Terms & Conditions as presented above.*

Business Information

Legal Business Name

Trade StyleType of BusinessBusiness Registration No

Telephone NumberFax NumberMobile NumberE-mail

Mailing AddressCity/TownProvincePostal Code

Is service to be provided to a different address from above?

Service AddressCity/TownProvincePostal Code

Business Principals/Partners

SurnameFirst NameMiddle Initial

Telephone NumberFax NumberMobile Number

Address: Same as business?Mailing AddressCity/TownProvincePostal Code

Date of BirthSocial Insurance NumberDo you have any off farms income?

ODSP$CPP$Rental$

OtherSpecify:$

Additional details:

SurnameFirst NameMiddle Initial

Telephone NumberFax NumberMobile Number

Mailing AddressCity/TownProvincePostal Code

Date of BirthSocial Insurance NumberDo you have any off farm income?

ODSP$CPP$Rental$

OtherSpecify:

All Applicants

Type of BusinessYears in BusinessAcres OwnedCrops GrownSpecify CropAcres RentedType of Livestock:Type of HogFarrow to FinishNurseryFinisherFarrow to WeanType of PoultryTurkeyBroilerBroiler BreederLayerPulletType of BeefCow CalfFinishingDairyGoatList Type of OtherOther

Banking Information

BankHow long at this branch?Full AddressTelephone NumberAccount NumberAccount Manager

Credit Suppliers

NameAddressName of ContactTelephone NumberFax Number

Terms & Authorization

$

Product or Service Required

I agree to the Terms & Conditions as presented above.

Finalize Before Submission:

Would you like to receive correspondence from HDC via:EmailMail

I confirm that all the above information is accurate and true*

Verify

Thank you for applying for an account with the Hensall District Co-Op allowing us to service your indicated requirements. Your application will be reviewed and a representative from our accounting department will reply within the next 7-10 business days.

If you have any questions regarding your application please contact either Pam Brand Accounts Receivable at pbrand@hdc.on.ca or Nick Fabiano Credit Manager at nfabiano@hdc.on.ca or by phone at 800-265-5190.

For further information please check out our website.

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