317 Green Bay Rd, Sturgeon Bay, WI 54235
(920) 743-6555 FAX (920) 743-6743

APPLICATION FOR CREDIT & MEMBERSHIP

WITH SUBSTITUTE FORM W-9 INFORMATION

All customers of Door County Cooperative Propane must fill out either
the Business Membership (with credit) or the Personal Member (with credit) form when applying.

TYPE OF MEMBERSHIP YOU ARE LOOKING FOR?*
- Business Membership (Non-Credit)
- Business Membership (With Credit)
- Personal Member (Non-Credit)
- Personal Member (With Credit)
Applicant Type*
- Single Applicant
- Joint Applicant
Personal Member (Non-Credit)
Personal Member (With Credit)
Name*
Prefix First Middle Last
Birth Date*
MM slash DD slash YYYY
Social Security Number*
Joint Applicant Name*
Prefix First Middle Last
Birth Date*
MM slash DD slash YYYY
Social Security Number*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Delivery Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
# Years At This Address*
Ownership*
Monthly Mortgage, Rent/Lease Payment*
Present Employer*
Position/Title*
Yrs.*
Gross Monthly Salary*
Other Income
Phone*
Phone (Alternative)
Email*
Make my account paperless*
- Yes
- No
Bank Institution And Branch*
Business Membership (Non-Credit)
Business Membership (With Credit)
Name of Entity and DBA (If Applicable)
Contact Name*
Prefix First Middle Last
Contact Title*
Business Address*
Street Address Address Line 2 City State ZIP Code
Delivery Address*
Street Address Address Line 2 City State ZIP Code
Federal ID or Social Security Number*
Type of Business*
Date Started*
MM slash DD slash YYYY
Crops and Acres Farmed (If Ag Business)
Annual Gross Income*
Annual Net Income*
Address of Headquarters*
Street Address Address Line 2 City State ZIP Code
Phone*
Phone (Alternative)
Email*
Make my account paperless*
- Yes
- No
Type*
If Other (Please Specify)*
Bank Institution and Branch*
Names of officers of corporation, other partners, or members of LLC
Officers and/or Partners, not required for Applicant/Joint Applicant
Names of Prior Business Owners (if in business/operation less than 3 years)
Authorized Agent Name (in addition to applicant)
CREDIT REFERENCES (3 Required)*
Name Address Phone
RETAIN A COPY OF THIS APPLICATION (YOU CAN DOWNLOAD AFTER FORM SUBMISSION FROM THE NEXT PAGE). IT CONTAINS THE TERMS AND CONDITIONS THAT WILL GOVERN THE RIGHTS OF THE PARTIES.

Please Read, Complete The Online Form and Sign
TERMS AND CONDITIONS OF CREDIT RELATIONSHIP

IN CASE OF ERRORS OR INQUIRIES ABOUT YOUR BILL
1. If you want to preserve your rights under the Act, here’s what to do if you think your bill is wrong or if you need more information about an item on your bill:
  1. A. Do not write on the bill. On a separate sheet of paper write (you may telephone your inquiry BUT DOING SO WILL NOT PRESERVE YOUR RIGHTS UNDER THIS LAW) the following:
    1. Your name and account number
    2. A description of the error and an explanation (to the extent you can explain) why you believe it is an error.
      If you need more information, explain the item you are not sure about and, if you wish, ask for evidence of the charge such as a copy of the charge slip. Do not send in your copy of a sales slip or other document unless you have a duplicate copy for your records.
    3. The dollar amount of the suspected error.
    4. Any other information (such as your address) which you think will help us to identify you or the reason for your complaint or inquiry.
  2. Send your billing error notice to the address on your bill which is listed after the words: “Send inquires to.”
    Mail it as soon as you can, but in any case early enough to reach us within 60 days after the bill was mailed to you.
2. We must acknowledge all letters pointing out possible errors within 30 days of receipt, unless we are able to correct your bill during that 30 days. Within 90 days after receiving your letter, we must either correct the error or explain why we believe the bill was correct. Once we have explained the bill, we have no further obligation to you even though you still believe there is an error, except as provided in paragraph 5 below.
3. After we have been notified, neither we nor a collection agency may send you collection letters or take other collection action with respect to the amount in dispute, but periodic statements may be sent to you, and the disputed amount can be applied against your credit limit. You cannot be threatened with damage to your credit rating or sued for the amount in question, nor can the disputed amount be reported to a credit bureau or to other creditors as delinquent until we have answered your inquiry. HOWEVER, YOU REMAIN OBLIGATED TO PAY THE PARTS OF YOUR BILL NOT IN DISPUTE.
4. If it is determined that we have made a mistake on your bill, you will not have to pay any finance charges on any disputed amount. If it turns out that we have no made an error, you may have to pay finance charges on the amount in dispute, and you will have to make up any missed minimum or required payments on the disputed amount. Unless you have agreed that your bill was correct, we must send you a written notification of what you owe; and if it is determined that we did make a mistake in billing the disputed amount, you must be given time to pay which you normally are given to pay undisputed amounts, before any more finance charges or late payment charges on the disputed amount can be charged to you.
5. If our explanation does not satisfy you and you notify us in WRITING WITHIN 10 days after you receive this explanation that you still refuse to pay the disputed amount, we may report you to the credit bureaus and other creditors and may pursue regular collection procedures. But we must also report that you think you do not owe the money, and we must let you know to whom such reports were made. Once the matter has been settled between you and us, we must notify those to whom we reported you as delinquent of the subsequent resolution.
6. If we do not follow these rules, we are not allowed to collect the first $50 of the disputed amount and finance charges, even if the bill turns out to be correct.
7. If you have a problem with property or services purchased, you may have the right not to pay the remaining amount due on them, if you first try in good faith.
The undersigned does hereby consent to take any qualified written notices of allocations of patronage refunds issued by Door County with respect to all patronage of the undersigned distribute with the association occurring during the current and all subsequent taxable years of the association, into account at their stated dollars amounts, for income tax purposes, in the year in which any such qualified written notices of allocations are received by the undersigned.

I agree that the following terms will govern any purchases made which are charged to any account that I may have with: Door County Cooperative.
1. Purchases made one month are due the 30th of the following month.
2. I understand that A FINANCE CHARGE OF 1.50%, which is an (ANNUAL PERCENTAGE RATE OF 18%) per year, will be applied to that part of any balance that resulted from purchases made during a calendar month, but not paid before the last of the following month plus any previous balance that remained unpaid.
3. Any payments or credits will be applied to the oldest amount owed. TERMS: Purchases made one month are due the 30th of the following month. A FINANCE CHARGE of 1.5% PER MONTH or 18% ANNUALLY will be charged on the previous balance less any payments or credits.
4. In the event that collection proceedings must be instituted to collect any balance due, I may be subject to statutory courts costs and attorney fees.
5. You have the right to amend the terms and conditions of this agreement by advising me of your intentions to do so in a manner and to the extent required by applicable law.
6. If applying for a Joint Account, both of us agrees to be bound by the terms of this agreement and each of us agree to be jointly and severally liable for payment of all purchases made under this agreement.
NOTICE TO MARRIED APPLICANTS: No provision of any marital property agreement, unilateral statement under s.766.59, Wis. Stats., or court decree under s.766.70 adversely affects the interest of the creditor unless the creditor, prior to the time the credit is granted or an open-end credit plan is entered into, is furnished a copy of the agreement, statement or decree of has actual knowledge of the adverse provision.

BY THE SIGNATURE BELOW, APPLICANT STATES THAT IT HAS READ, UNDERSTANDS, AND AGREES TO THE TERMS AND CONDITIONS SET FORTH HEREIN AND FURTHER CERTIFIES THAT ALL OF THE INFORMATION CONTAINED IN THE APPLICATION AND ANY ATTACHMENTS IS TRUE AND CORRECT TO THE BEST OF THEIR INFORMATION, KNOWLEDGE, AND BELIEF AND FURTHER CERTIFIES THAT HE/SHE IS AUTHORIZED TO EXECUTE THIS APPLICATION ON BEHALF OF APPLICANT.
APPLICANT NAME*
Date*
MM slash DD slash YYYY
Signature*
JOINT APPLICANT*
Date*
MM slash DD slash YYYY
Signature*
APPLICANT SHOULD RETAIN A COPY OF THIS APPLICATION (YOU CAN DOWNLOAD AFTER FORM SUBMISSION FROM THE NEXT PAGE) AS IT CONTAINS THE TERMS AND CONDITIONS THAT WILL GOVERN THE RIGHTS OF THE PARTIES SHOULD CREDIT BE EXTENDED.
PERSONAL GUARANTEE – FOR BUSINESS ENTITY APPLICANTS

For and in consideration of Door County Cooperative (DCC) extending credit to the business named in this Application, the digitally undersigned hereby personally guarantee to DCC the payment of any obligation of the business or its successors and I hereby agree to bind myself to pay DCC on demand any sum which may become due to DCC by the business whenever the business or its successors shall fail to pay the same. It is understood that this guarantee shall be a continuing and irrevocable guaranty and indemnity for all indebtedness of the business or its successor(s). The digitally undersigned hereby waive notice of default, non-payment and notice thereof and consent to any modification or renewal of the credit agreement hereby guaranteed.
Name*
Date*
MM slash DD slash YYYY
Signature*
Name
Date
MM slash DD slash YYYY
Signature

WHY BE A MEMBER?

The Door County Cooperative is democratically controlled by owners who use or provide the co-op's goods and services. Each owner gets to vote to help make the organization's policies and decisions.

Door County Cooperative member/owners have the potential to receive a percentage of Door County Cooperative profits paid back to them annually in the form of payouts or "patronage dividend distributions".

Name	Address	Phone

Name	Address	Phone

317 Green Bay Rd, Sturgeon Bay, WI 54235 (920) 743-6555 FAX (920) 743-6743

APPLICATION FOR CREDIT & MEMBERSHIP

WITH SUBSTITUTE FORM W-9 INFORMATION

TERMS AND CONDITIONS OF CREDIT RELATIONSHIP

WHY BE A MEMBER?

317 Green Bay Rd, Sturgeon Bay, WI 54235
(920) 743-6555 FAX (920) 743-6743