This fuel card account application (the "application") relates to fuel card and miscellaneous Merchandise ONLY. If approved, short-term credit will be extended by and can be utilized by applicant solely for fuel card and misc. Merchandise purposes. Gold-Eagle Cooperative is not a finance company and expects prompt on-time payment for outstanding balances.
PRIMARY APPLICANT FULL LEGAL NAME (FIRST, MIDDLE, LAST)
PRIMARY APPLICANT TITLE (IF APPLICABLE)
PRIMARY APPLICANT ADDRESS
PRIMARY APPLICANT CITY
PRIMARY APPLICANT STATE
PRIMARY APPLICANT ZIP CODE
PRIMARY APPLICANT HOME PHONE
PRIMARY APPLICANT MOBILE PHONE
PRIMARY APPLICANT EMAIL ADDRESS
PRIMARY APPLICANT SOCIAL SECURITY NUMBER
PRIMARY APPLICANT DATE OF BIRTH
PRIMARY APPLICANT MARITAL STATUS (REQUIRED FOR SOLE PROPRIETORSHIP)
Married
Separated
Unmarried
CO-APPLICANT FULL LEGAL NAME (FIRST, MIDDLE, LAST)
CO-APPLICANT TITLE (IF APPLICABLE)
CO-APPLICANT ADDRESS
CO-APPLICANT CITY
CO-APPLICANT STATE
CO-APPLICANT ZIP CODE
CO-APPLICANT HOME PHONE
CO-APPLICANT MOBILE PHONE
CO-APPLICANT EMAIL ADDRESS
CO-APPLICANT SOCIAL SECURITY NUMBER
CO-APPLICANT DATE OF BIRTH
CO-APPLICANT MARITAL STATUS (REQUIRED FOR SOLE PROPRIETORSHIP)
Married
Separated
Unmarried
Primary Bank (Including Branch)
Primary Bank Phone Number
Annual Income
I AGREE THAT THE FOLLOWING TERMS WILL GOVERN ANY PURCHASES MADE WHICH ARE CHARGED TO ANY GAS CHARGE ACCOUNT THAT I MAY HAVE WITH GOLD-EAGLE COOPERATIVE
“GEC”.
1. BALANCE DUE IN FULL BY THE 15TH OF THE MONTH FOLLOWING MONTH OF PURCHASE. WE WILL NOT CHARGE INTEREST ON YOUR PURCHASES IF YOU PAY YOUR
ENTIRE BALANCE BY THE DUE DATE EACH MONTH.
2. UNPAID BALANCE WILL BE ASSESSED A FINANCE CHARGE OF 1.5%, WHICH IS AN APR OF 18% PER YEAR STARTING ON THE 16TH OF THE MONTH (THIS RATE IS
SUBJECT TO CHANGE WITH NOTICE ON THE MONTHLY STATEMENT).
3. PAYMENTS SHALL BE FIRST APPLIED TO THE UNPAID FINANCE CHARGE AND THE REMAINING TO THE UNPAID BALANCE.
4. IN THE EVENT COLLECTION ACTION BECOMES NECESSARY TO COLLECT ON YOUR ACCOUNT, ANY AND ALL COSTS INCURRED BY, INCLUDING COLLECTION SERVICE
PAYMENTS, COURT COSTS, AND ATTORNEY FEES WILL BE APPLIED TO YOUR ACCOUNT.
5. IF APPLYING FOR A JOINT ACCOUNT, BOTH OF THE UNDERSIGNED APPLICANTS AGREE 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, INTEREST, AND COSTS OF COLLECTION, PURSUANT TO THIS AGREEMENT.
6. GEC SHALL HAVE THE RIGHT TO LIMIT OR TERMINATE MY GAS CARD CHARGE ACCOUNT, BUT TERMINATION SHALL NOT AFFECT APPLICANT’S OBLIGATION TO PAY AN
EXISTING BALANCE. UPON DEFAULT OF PAYMENTS, GEC MAY DECLARE THE ENTIRE BALANCE DUE AND PAYABLE IMMEDIATELY.
THIS DOCUMENT AUTHORIZES THE RELEASE OF ANY AND ALL OF APPLICANT’S AND/OR CO-APPLICANT’S FINANCIAL INFORMATION TO GEC BOARD MEMBERS, MANAGEMENT, LEGAL
ADVISORS, AND ACCOUNTANTS, AND RELEASES GEC AS THE CUSTODIAN OF SUCH RECORDS, BOTH INDIVIDUALLY AND COLLECTIVELY, FROM ANY AND ALL LIABILITY FOR DAMAGES WHICH
MAY RESULT DUE TO RELEASE OF THIS INFORMATION PURSUANT TO THIS AUTHORIZATION.
THE UNDERSIGNED FURTHER AUTHORIZES GEC TO OBTAIN CONSUMER CREDIT REPORTS FROM CREDIT BUREAUS OR PARTNER CREDIT AGENCIES AND SHARE ANY AND ALL INFORMATION
IN THEIR CARE, CUSTODY, AND CONTROL CONCERNING THE UNDERSIGNED APPLICANT AND/OR CO-APPLICANT AS WELL AS ANY INFORMATION RECEIVED PURSUANT TO THIS
AUTHORIZATION. THIS AUTHORIZATION IS VALID FOR 180 DAYS.
THE UNDERSIGNED ACKNOWLEDGES RECEIPT OF CREDIT CARD APPLICATION DISCLOSURE STATEMENT.
IT IS EXPRESSLY AGREED THAT A PHOTOCOPY OF THIS AUTHORIZATION SHALL BE AS VALID AS AN ORIGINAL.
Primary Applicant Signature
Date
Co-Applicant Signature
Date
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