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Consumer Account Application


Please complete the form online. You can print it after it is completed.

Fields marked with * are required.


Customer information

Surname: * Firstname: * Middle Initial:
Date of Birth: *Month Day Year
Social Insurance Number: (optional)
Email Address: *
Telephone Numbers
Home Phone: * Cellphone: Fax:
Mailing Address
Street: * City: *
Province: * Postal: *
Delivery Address(if different from above)
Street: City:
Province: Postal:

Employment

Employer: *
Years of service: *
Gross Monthly Salary: *
Do you have additional income?
YesNo

Additional Income

Amount(Monthly): *
Description: *

Is there a Co-applicant?YesNo
Co-applicant
Surname: * Firstname: * Middle Initial:
Date of Birth: *Month Day Year
Social Insurance Number: (optional)
Email Address:
Telephone Numbers
Home Phone: Cellphone: Fax:
Employer: *
Years of service: *
Gross Monthly Salary: *


Have you lived at this address for less than 2 years?
Yes No

Previous Mailing Address
  Street: City:
  Province: Postal:
Do you own or rent your home?RentOwn

Name of landlord: *
Landlords Phone Number: *


Bank and Credit Information

Bank information

Bank name: * How long at this branch(years):   
Account Number: Account Manager: 
Mailing Address
Street:  City: * Province:  Postal:

Credit Suppliers

Supplier 1
Name: Address: Contact name:
Telephone Number: Fax Number:
Supplier 2
Name: Address: Contact name:
Telephone Number: Fax Number:




Credit and Service Information

Amount of credit requested:

*Services Required


Please select
at least 1.
Energy
Propane
Delivery address:
Furnace Oil
Delivery address:
Gas
Delivery address:
Diesel
Delivery address:


Feed Swine
Farrow to Finish Number housed
Feeders Number housed
Dairy
Cows Milked Number of head
Broiler
Broilers Number Housed
Layer
Layers Housed
Beef
Beef Number of head
Turkey
Turkeys Number Housed
Goats
Goats Milked Number
Goats fed Number
Other Feed

Crops Seed
Chemicals
Fertilizer

Other Other
Comments:

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 a
ny 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.
By selecting Agree and clicking "Apply for credit", you agree to the terms and conditions above.AgreeNotAgree
HDC Logo Hensall District Co-operative Inc.
1 Davidson Drive, P.O. Box 219,
Hensall ON N0M 1X0
TF: 1-800-265-5190 | T: 519-262-3002 | F: 519-262-2317