Credit Application | CPI - Cooperative Producers, Inc.

Type of ApplicantIndividual / Sole ProprietorEntityType of Applicant

Individual / Sole Proprietor Information

First & Last NameApplicant_UserName

MI *Middle Initial Applicant10 / 1

Date of Birth *

Date of Birth

Mailing Address *Applicant Mailing Address

City *Applicant City

State/Province *Applicant State

ZIP / Postal Code *Applicant Zip Code

Phone/Cell Number *Applicant Phone Number

Email *Applicant Email Address

Driver's License # *Driver's License Number0 / 20

SSN *SSN Applicant10 / 11

Employer & Occupation *Employer & Occupation

Employer Phone NumberEmployer Phone Number

Are you applying with a spouse / co-applicant? *YesNoApplying with Co-Applicant

Spouse / Co-Applicant Information

Last Name *Last Name Co-Applicant1

Legal First Name *First Name Co-Applicant1

MI *Middle Initial Co-Applicant10 / 1

Date of Birth *

Date of Birth Co-Applicant

Phone/Cell NumberPhone Number Co-Applicant

Email *Email Address Co-Applicant

Driver's License # *Driver's License Number Co-Applicant0 / 20

SSN *SSN Co-Applicant10 / 11

Employer & Occupation *Employer & Occupation Co-Applicant

Employer Phone NumberEmployer Phone Number Co-Applicant

Specify Entity Type *Other

Entity Information

Entity Name - as shown on your income tax return *Entity Name

Date of Incorporation / Organization *Date of Incorporation/Organization

State *State of Entity

Federal ID Number *Federal ID Number

Name of SubsidiariesName of Subsidiaries

Entity Mailing Address *Entity Mailing Address

City *Entity City

State *Entity State

ZIP / Postal Code *Entity Zip Code

Email *Entity Email Address

Phone Number *Entity Phone Number

Alt. Phone NumberEntity Alt Phone Number

Owner InformationOwner Information

Last Name *Last Name Owner1

First Name *First Name Owner1

MI *Middle Initial Owner10 / 1

SSN *SSN Owner1

Date of Birth *

DOB Owner1

% Owner *% Owner1

Entity Mailing Address *Mailing Address Owner1

City *City Owner1

State *State Owner1

ZIP *Zip Code Owner1

Note

You can add additional owner information once you complete the form in Docusign.

Limited Financial Information

Gross Farm/Business Income *Gross Farm/Business Income

Amount of Annual Debt Service Payments *Amount of Annual Debt Service Payments

Applicant's Total Assets *Applicant's Total Assets

Applicant's Total Liabilities *Applicant's Total Liabilities

List Other Income and Source(s) *Other Income and Source(s) other than farming

List Names of Creditors and Amounts Owed to Each *Names of creditors and amounts owed to each

Primary Bank ReferencePrimary Bank Reference

Bank Name *Bank Name

Contact Name *Contact Name

Mailing Address *Primary Bank Mailing Address

City *Primary Bank City

State *Primary Bank State

ZIP *Primary Bank Zip Code

Phone Number *Primary Bank Phone Number

Fax Number *Primary Bank Fax Number

Other Credit Reference (Non-Bank or Credit Card)Other Credit Reference

Name *Name of Other Credit Reference-1

Mailing Address *Mailing Address Other Credit Reference-1

City *City Other Credit Reference-1

State *State Other Credit Reference-1

ZIP *Zip Code Other Credit Reference-1

Phone Number *Phone Number Other Credit Reference-1

Fax Number *Fax Number Other Credit Reference-1

Other Credit Reference (Non-Bank or Credit Card)Other Credit Reference

Name *Name of Other Credit Reference-2

Mailing Address *Mailing Address Other Credit Reference-2

City *City Other Credit Reference-2

State *State Other Credit Reference-2

ZIP *Zip Code Other Credit Reference-2

Phone Number *Phone Number Other Credit Reference-2

Fax Number *Fax Number Other Credit Reference-2

Production InformationProduction Information

Total Acres Owned *Total acres owned

Total Acres Rented *Total acres rented

Total Acres Farmed *Total acres farmed

CPI Credit Application

Purchases (select all that apply)

Company

Grain

Agronomy

Energy

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