Personal Credit Application

Account Type*

Joint
Individual

Monthly Credit Request (est.)*

Name*

First Last

Marital Status*

Spouse*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Service/Shipping Address (if different from above)

Street Address Address Line 2 City State ZIP Code

County*

First

Primary Phone*

Primary Phone Type*

Secondary Phone

Secondary Phone Type*

Birth Date*

Spouse's Birth Date*

Social Security Number*

Spouse's Social Security Number*

Email*

Have you lived at your current address for less than 5 years?*

Yes
No

Previous Address*

Street Address Address Line 2 City State ZIP Code

Are you currently retired?*

Yes
No

Business/Employer*

Position*

Years on the Job*

Employer Address*

Street Address Address Line 2 City State ZIP Code

Income*

Spouse's Employer*

Spouse's Position*

Spouse's Years on the Job*

Spouse's Employer Address*

Street Address Address Line 2 City State ZIP Code

Spouse's Income*

Product*

Check all that apply

Other Product

Would you like a fuel card?*

Yes
No

Number of Cards

I agree to pay the full purchase price for all goods, materials, equipment and/or services purchased from Centerra Co-op within the terms on my invoice or monthly account statement. If I do not make a full payment within the terms on my invoice or monthly statement, I agree that, in addition to any unpaid balances of principal, I will be subject to and hereby agree to pay a service charge of one and one-half percent (1.5%) per month (annual percentage rate of 18%), in addition to Centerra Co-op’s attorney fees incurred in collecting all delinquent account balances. I further agree to be bound by all the terms and conditions set forth on the back of this application. My signature below indicates that I have read, understood, agree and covenant to be bound by the terms set forth in this Application and Centerra Co-op’s invoices and account statements and that all information I have provided herein is true and accurate.

Signature*

Spouse's Signatre*

Personal Credit Application

My Account