Greenleaf Wi Cornette Farm Supply New Client Form
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1P.O. BOX 19
GREENLEAF, WI 54126
(920) 864-3333
1-800-236-4810
Along with the Charge Account Form and Tax Exempt Form, please fill out the following bank information.
Also, please list below 3 businesses that we may contact for credit information. If you have any questions
please call our office. Thank You for choosing Cornette Farm Supply.
BANK NAME:
________________________________________________
PHONE:
_(______)________________________________________
CONTACT PERSON:
________________________________________________
(1) BUSINESS NAME:
________________________________________________
ADDRESS:
________________________________________________
________________________________________________
PHONE:
_(_____)_______________ FAX: (_____)_______________
CONTACT PERSON:
________________________________________________
(2) BUSINESS NAME:
________________________________________________
ADDRESS:
________________________________________________
________________________________________________
PHONE:
_(_____)_______________ FAX: (_____)_______________
CONTACT PERSON:
________________________________________________
(3) BUSINESS NAME:
________________________________________________
ADDRESS:
________________________________________________
________________________________________________
PHONE:
_(_____)_______________ FAX: (_____)_______________
CONTACT PERSON:
________________________________________________
The undersigned hereby: (1) authorize Cornette Farm Supply, Inc. to obtain from any credit reporting agency any business and/or
personal credit report relating to the above named Applicant, and the undersigned individuals; (2) authorize any bank, lender, or other
guarantor of credit to provide Cornette Farm Supply, Inc. copies of Applicant's balance sheets and income statements and other credit-
related information; (3) releases Cornette Farm Supply, Inc. and any bank or lender or reporting agency from any and all claims or
causes of action that may arise by reason of the information provided to Cornette Farm Supply, Inc.. (4) agrees to the above account
terms and acknowledge that all of the above information is true and correct and that account privileges may be terminated without notice
at the discretion of Cornette Farm Supply, Inc.. Each individual Applicant signing this Application agrees to be obligated jointly and
severally according to the terms and conditions set forth above.
Signature of Applicant: ______________________________________________________ Date: _________________________
Please Print: ______________________________________________________________________________________________
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