CARDTROL CREDIT APPLICATION

Farm Service Cooperative

CARDTROL CREDIT APPLICATION

NAME __________________________ SPOUSE’S NAME___________________
SS # __________________________ SPOUSE’S SS# _____________________
ADDRESS________________________ CITY____________ STATE___ ZIP______

TELEPHONE: HOME___________________ WORK_______________________
E-MAIL____________________________ FAX_____________________________

PREVIOUS ADDRESS: (if lived at current address less than one year)
ADDRESS_______________________ CITY____________ STATE____ ZIP______

LIST EMPLOYER AND ADDRESS:_______________________________________
SPOUSE'S EMPLOYER AND ADDRESS:__________________________________

BANK NAME AND ADDRESS:__________________________________________
________________________________________

CREDIT REFERENCES:

NAME	ADDRESS	PHONE
______________________	______________________	______________________
______________________	______________________	______________________
______________________	______________________	______________________

PLEASE READ BEFORE SIGNING THIS APPLICATION

The above information is for the purpose of obtaining credit and is warranted to be true.

I agree to pay all invoices in accordance with Farm Service Cooperative policy.

I hereby authorize Farm Service Cooperative, any credit bureau or other investigative agency employed by Farm Service Cooperative to investigate the references herein listed or statements or other data obtained from me or from any other person pertaining to my credit and financial responsibility.

Signature(s)__________________________________________

__________________________________________ Date_____________

Farm Service Cooperative

CARDTROL APPLICATION

NAME _______________________________ ACCT NO.___________________

ADDRESS_____________________________ PHONE NO._________________

CITY_________________________________ STATE______ ZIP___________

Products that I will use: (Check all that apply)
Unleaded _____ Super Unleaded _____ Diesel-Farm Use _____ Diesel-Over the road _____

Number of cards desired ___________

Quantity needed per fill - maximum 250 gallons:
This is the largest tank capacity to be filled at one time. This limit is used for your operating safety.

10 20 30 40 50 70 100 150 250

Different or Identical PIN Numbers for each card?________________

A PIN number is a personal identification number. This is a special four digit identification number which must be manually entered at the card reader every tine you want to get fuel. A PIN number is used for extra security. Should your card be lost or stolen, no one else could pick up your card and use it.

Any other questions that you may have?

__________________________________________________________________

CARDTROL CONTRACT

THIS AGREEMENT, made and entered into this ______ day of ________, 20__, by and between Farm Service Cooperative, (Seller), 2308 Pine Street, Harlan, Iowa, and ______________, whose address is _________________________________, (Buyer).

1. CARD Seller herby agrees to provide Buyer with a card which will operate Sellers card control fuel stations.
PIN (Personal Identification Number) Requested. Yes_______ No_______

2. PURCHASES Seller herby agrees to allow Buyer to purchase such quantities of fuel as Buyer shall require and Seller is able to supply for so long as Seller is able to supply the same without restriction or rationing. Said purchases may be made by Buyer by utilizing the card in Seller's card control pumps.

3. LIABILITY FOR PURCHASE Buyer hereby agrees to pay seller for any and all products purchased through the use of said card, PROVIDED however that Buyer may terminate his liability for purchases made with said card by:

(1) Returning to Seller any and all cards remaining in Buyer's possession, or
(2) Notifying Seller that said cards have been lost or stolen.

Said notice to Seller, if given orally to Seller, shall be given to any employee of Seller during Sellers regular business hours at Sellers' place of business in Harlan, Iowa and shall be effective for a period of 48 hours from such notice, during which time Buyer shall so notify Seller in writing.

Said notice to Seller if written shall be mailed or delivered to Seller at Sellers address first above stated and shall be effective upon Sellers actual receipt of the same.

4. TERM AND TERMINATION This agreement may be terminated at any time as follows:

(1) Buyer may terminate this agreement by complying with the provisions for lost or stolen cards as provided in 3. above, provided however, that Buyer remains responsible for purchases made prior to such notice. Upon return to Seller all cards issued to Buyer, when such return is evidenced by written receipt from Seller to Buyer, the oral and written notices provided in Section 3 paragraph 2 (b) shall not be required.
(2) Seller may terminate this agreement without notice to Buyer by removing the card control pump or by causing the same to be inoperative, or by changing said pump so that Buyer's card will no longer operate the same, and Buyer remains responsible for purchases made prior to such termination.

5. CREDIT POLICY Buyer hereby agrees to pay Seller for purchases made under this agreement at the rate per gallon stated in Sellers periodic billing statement. Buyer further agrees to pay Seller as provided in Sellers Credit policy, in which, Buyer agrees to pay Seller for the total purchases made on or before the 15th day of the month following the month of purchase. Buyers' failure to keep said account current as provided in this section, shall entitle Seller to terminate this agreement pursuant to Section Four (2).

THE UNDERSIGNED HEREBY UNCONDITIONALLY GUARANTEE(S) PAYMENT WHEN DUE, and agree(s) to pay all expenses (including attorneys' fees and legal expenses) incurred by the Company to collect the debt and in enforcing this guarantee.

6. MISCELLANEOUS

Buyer understands and agrees, that the dollar amount of purchases shall conclusively be established by the records provided by said card control pumps unless Buyer can demonstrate that said card control pumps has malfunctioned.
Seller agrees to allow reasonable inspection of its card control pumps by any regulatory agency and Seller further agrees to cause said pump to be properly maintained and in a state of good repair, provided however that should Buyer determine that said pumps are not being properly inspected or maintained, Buyer remedy is to terminate this agreement as provided above.
The provisions of this section are not intended to limit or otherwise restrict Buyers right to dispute any billing errors.
Buyer understands that Seller will not have an attendant to supervise the operation of the card control pump. Buyer hereby acknowledges that Seller has demonstrated and explained how to safely operate said pumps.
Buyer hereby agrees that he will assume the responsibility for and will reimburse Seller for any damage which may be caused to said pumps or the Sellers other facilities and equipment located on the service station premises by Buyer negligence, or failure to observe Seller's rules.
Buyer agrees to hold Seller harmless for any injury, or damage to Buyers person, employees or agents or property which may result form the negligence or failure to observe Sellers safety rules, by Buyers or Buyers employees or agent.

7. This agreement shall be binding upon the parties hereto, their heirs, administrators, executors, trustees, successors, and assigns, PROVIDED HOWEVER, that this agreement is not assignable by Buyer.

Seller:__________________________________

by:__________________________________
Buyer:__________________________________

__________________________________

Note: If Buyer is a corporation the corporate name should be stated, and the title of Purchasers agent signing agreement; if Buyer is partnership, each partner must sign the agreement.

Please Return to: Farm Service Cooperative
PO Box 429

Harlan, IA 51537
or Fax to: 712-755-7098