Commercial Credit Application

770 N High School Road, Indianapolis, IN 46214

PHONE: (800) 525-0272
COMMERCIAL CREDIT APPLICATION
ALL INFORMATION WILL BE TREATED IN A CONFIDENTIAL MANNER.
CREDIT AMOUNT REQUESTED:*
ENTITY TAX ID:*
For Sole Proprietorship, enter SSN. Other entities provide TID.
ENTITY NAME:*
PARENT COMPANY NAME:
IS GROSS ANNUAL REVENUE LESS THAN $25 MILLION?*

YESNO
YEARS IN OPERATION:
PHONE:*
EMAIL ADDRESS:*
example@example.com
BILLING ADDRESS:*

STREET ADDRESS

Street Address Line 2

CITY/STATE/ZIPState / Province

Postal / Zip Code
IF LESS THAN 3 YEARS AT CURRENT ADDRESS:

PREVIOUS STREET ADDRESS

Street Address Line 2

CITY/STATE/ZIPState / Province

Postal / Zip Code

APPLICANT / OWNERSHIP INFORMATION
APPLICANT / OWNER 1
NAME:*
Phone Number:*
Please enter a valid phone number.
Date of Birth:

MonthDayYear
Date
TITLE:*
SSN:*
APPLICANT / OWNER 2
NAME:
Phone Number:
Please enter a valid phone number.
Date of Birth:

MonthDayYear
Date
TITLE:
SSN:
APPLICANT / OWNER 3
NAME:
Phone Number:
Please enter a valid phone number.
Date of Birth:

MonthDayYear
Date
TITLE:
SSN:

TAX EXEMPTION INFORMATION
WILL YOU CLAIM ANY TAX EXEMPTION? PLEASE COMPLETE THE STATE RELATED EXEMPTION FORM AND ATTACH AT THE END OF THE APPLICATION.

YESNO
IF TAX EXMEMPT, ENTER TAX EXEMPT #:

BANKING REFERENCE
NAME OF BANKING INSTITUTION:
BANK ADDRESS:
NAME ON BANK ACCOUNT:
BANK PHONE:

AUTHORIZATION / APPROVALS

BUSINESS ENTITY, CORPORATION, LLC, OR PARTNERSHIP, PLEASE COMPLETE THIS SECTION.
WHO IS AUTHORIZED TO USE/ORDER FOR THIS ACCOUNT?*
AUTHORIZED USER PHONE:*
WILL A PURCHASE ORDER BE REQUIRED?*

YESNO
NAME OF ACCOUNTS PAYABLE MANAGER:
ACCOUNTS PAYABLE MANAGER EMAIL:
example@example.com
DOES ANY PRINCIPLE OWNER OF THIS COMPANY HAVE AN OWNERSHIP INTEREST IN ANY ENTITY THAT HAS A CREDIT ACCOUNT WITH KEYSTONE?*

YESNO
WHAT BUSINESS NAMES AND ACCOUNT NUMBERS?*

TRADE REFERENCES

PLEASE PROVIDE TWO TRADE REFERENCES OR UPLOAD A TRADE REFERENCE SHEET AND FINANCIALS.
(1) REFERENCE NAME:*
(2) REFERENCE NAME:
TYPE OF ACCOUNT:*
TYPE OF ACCOUNT:
LINE OF CREDIT / LIMIT:*
LINE OF CREDIT / LIMIT:
CURRENT BALANCE:*
CURRENT BALANCE:
CREDIT REFERENCE PHONE NUMBER:*
CREDIT REFERENCE PHONE NUMBER:
CREDIT REFERENCE EMAIL ADDRESS:*
example@example.com
CREDIT REFERENCE EMAIL ADDRESS:
example@example.com

FUEL CARD SETUP
TERMS AND CONDITIONS:

These terms and conditions (“Terms”) are entered into between Keystone Cooperative, Inc. (“Keystone”) and the individual/entity named below (“Purchaser”) and govern Purchaser’s use of the payment card(s) issued to Purchaser by Keystone and linked to the Keystone Account Number identified above (“Fuel Cards”). The Fuel Cards may be used at locations that accept Fuel Cards to obtain fuel and other available goods or services. By signing below, Purchaser agrees to the following:

1. The Fuel Cards may only be used for purchases of fuel or services for vehicles owned and/or operated by Purchaser.
2. Purchaser understands that the Fuel Cards are not credit cards and the federal $50.00 liability limit for credit cards will not apply.
3. All purchases made using the Fuel Cards will be the responsibility of Purchaser, whether made by Purchaser, any of its authorized users, or any other persons using the Fuel Cards, and regardless of whether use of the Fuel Card is authorized or is fraudulent. Purchaser is responsible for managing any authorized users of the Fuel Cards.
4. Purchaser shall immediately notify Keystone of a lost, stolen, or misused Fuel Card and when a Fuel Card needs to be invalidated. Purchaser agrees that it will not have the PIN#/security access code on/near the Fuel Card should it be lost or become used fraudulently in any way.
5. Purchaser represents that it will ensure all persons using the Fuel Cards are aware of the proper use of the Fuel Cards and shall use safe practices in compliance with all applicable laws and regulations in the handling of the fuels dispensed and purchased through a Fuel Card. When making any such purchases, Purchaser agrees to be responsible for any related spills or fueling facility/equipment damage, whether accidental or due to negligence of Purchaser or the user of the Fuel Card. Purchaser further understands and acknowledges that off-road or dyed diesel fuel is illegal for use in any on-road vehicle. Significant fines and/or penalties may be levied against the Purchaser and/or users for any intentional or unintentional dispensing of off-road or dyed diesel into the fuel tank of any on-road vehicle.
6. Keystone shall use its best efforts to maintain the fuel card system in good working order and condition at its expense, provided however that Keystone shall not be responsible for any damage or loss which may result from Keystone’s failure to provide fuel or the failure of a Fuel Card to be utilized by Purchaser in any manner whatsoever. Purchaser agrees that it and any person using the Fuel Cards shall promptly notify Keystone of any malfunctioning of the Fuel Card of which Purchaser or such person is aware.
7. Purchaser’s right to purchase fuel using a Fuel Card may be terminated immediately by Keystone upon any breach by Purchaser of any of the terms hereof or of any other agreement with Keystone. Upon termination, Purchaser agrees to immediately surrender all Fuel Cards issued to Purchaser and to immediately pay all outstanding sums owing to Keystone. Keystone shall refund any deposit to Purchaser when all Fuel Cards are returned and all amounts owing to Keystone are paid in full.
8. Transaction data for each Fuel Card will be posted on the Keystone Account identified above. Keystone will report the data received from merchants and as such is not liable for accuracy or completeness of the data received, posted, or contained in any specialty reports, management reports, data services, or other information services provided. The availability of data is dependent upon each merchant’s adoption of card specifications and the information, including product codes, that the merchant transmits to Keystone. Purchaser is responsible for reconciling such transaction data. In addition, Purchaser understands that in the event an error is identified in a report, such as incorrect product code, Purchaser is still liable for the purchase, but may follow the dispute process to obtain clarifying information.
9. Certain security controls may be put in place by Keystone or a merchant to protect against fraudulent activity, including capping the number of transactions in a day and certain other limits in relation to use of the Fuel Cards (“Controls”). Keystone shall use reasonable efforts to deny requests for transaction authorizations that fall outside the set Controls. Purchaser acknowledges and agrees that it remains responsible for payment in full of transactions which fall outside of the set Controls if such transactions are made with a valid Fuel Card and are processed by Keystone. The existence and/or use of Controls will not affect Purchaser’s liability for unauthorized transactions. Only transactions submitted for authorization are subject to Controls and those set Controls can only be enforced when the merchant provides sufficient information as part of the authorization. Keystone may, in its sole discretion and/or without prior notice, modify the Controls for the purpose of, among others, the prevention of suspected fraudulent activity. Keystone will notify Purchaser after any modification is made. Purchaser agrees it is responsible for reviewing fraud control data provided by Keystone for the purpose of detecting fraud that may occur within the set Controls.
10. TO THE FULLEST EXTENT PERMITTED BY LAW, KEYSTONE WILL NOT BE LIABLE FOR (I) ANY INDIRECT, SPECIAL, CONSEQUENTIAL, INCIDENTAL, PUNITIVE, OR EXEMPLARY DAMAGES OR LOSSES, WHETHER OR NOT FORESEEABLE, (II) ANY LOSS OR DAMAGES ARISING DIRECTLY OR INDIRECTLY FROM OR IN CONNECTION WITH ANY INACCURACY, ACT, OR FAILURE TO ACT ON THE PART OF ANY PERSON NOT WITHIN KEYSTONE’S REASONABLE CONTROL, OR ANY ERROR, FAILURE, OR DELAY IN EXECUTION OF ANY TRANSACTION RESULTING FROM CIRCUMSTANCES BEYOND KEYSTONE’S REASONABLE CONTROL, INCLUDING, BUT NOT LIMITED TO, ANY INOPERABILITY OF FUEL CARDS OR OTHER TECHNOLOGICAL FAILURE, AND (III) ANYTHING EXCEPT FOR ITS OWN GROSS NEGLIGENCE OR WILLFUL MISCONDUCT. PROVIDED KEYSTONE HAS COMPLIED WITH ITS OBLIGATIONS UNDER THESE TERMS, AND SUBJECT TO APPLICABLE LAW, PURCHASER AGREES TO INDEMNIFY, DEFEND, AND HOLD KEYSTONE HARMLESS AGAINST ANY THIRD-PARTY CLAIM ARISING FROM, OR IN CONNECTION WITH, DIRECTLY OR INDIRECTLY, (I) PURCHASER’S, OR ANY PERSON’S, USE OF ANY FUEL CARD, (II) PURCHASER’S BREACH OF ANY OF THE TERMS SET FORTH HEREIN, OR (III) PURCHASER’S OR ANY OF ITS FUEL CARD USERS’ NEGLIGENCT OR INTENTIONAL ACTS OR OMISSIONS.
HOW MANY FUEL CARDS WILL YOU NEED?*
If multiple cards are requested Keystone will contact you for Card User Information to set up each card.
AUTHORIZED ACCOUNT USERS

Purchaser authorizes the below individuals to order Fuel Cards and make changes to Fuel Cards, such as terminating certain Fuel Cards, on behalf of Purchaser.
HOW MANY INDIVIDUALS WILL BE AUTHORIZED ON THE ACCOUNT?*
Please list authorized users on the account below - not fuel card users.
NAME:*

First NameLast Name
TITLE:*
PHONE NUMBER:*
Please enter a valid phone number.
EMAIL:*
example@example.com
NAME:*

First NameLast Name
TITLE:*
PHONE NUMBER:*
Please enter a valid phone number.
EMAIL:*
example@example.com
NAME:*

First NameLast Name
TITLE:*
PHONE NUMBER:*
Please enter a valid phone number.
EMAIL:*
example@example.com
NAME:*

First NameLast Name
TITLE:*
PHONE NUMBER:*
Please enter a valid phone number.
EMAIL:*
example@example.com
The below individual represents that it has authority to enter into these Terms and agrees to all of the terms and conditions set forth above.
NAME:*

First NameLast Name
TITLE:*
SIGNATURE:*

Clear
DATE:*

MonthDayYear
Date

PLEASE READ LEGAL TERMS BELOW. TERMS APPLY TO ALL ACCOUNTS. PLEASE SIGN AS APPROPRIATE.

Everything I have stated in this application or information that l have submitted with this application is accurate and true. If Keystone Cooperative, Inc. receives an insufficient funds check from the account holder, and/or as a condition of establishing credit, the following applies. I/We agree to pay the balance due and in addition all applicable FINANCE CHARGES which I/we hereby agree to pay in accordance to all terms and conditions in which I/we are notified from time to time, including but not limited to periodic statements sent to me setting forth the outstanding obligations I/we have to you. All parties agree the laws of the State of Indiana will apply to any dispute regarding this credit application on any amount owed on a Keystone account. I/We hereby agree to pay all attorney fees and court costs if this account is referred to attorneys for collection, without relief from valuation and appraisement laws. In accordance with Article 9 Section 402 of the UCC Code, the buyer further grants to seller a security interest in buyer’s equipment, contract rights, inventories, receivables and proceeds of sales as collateral to secure the buyer’s performance of all obligations. I/we hereby acknowledge Keystone may run a lien search for the entity or individual applying for credit. The applicant further authorizes Keystone to file a financing statement without applicant’s signature. A 1.75% finance charge will be added monthly to all past due balances. This is an annual rate of 21%. By signing, I authorize Keystone to investigate my credit record and report to proper persons and bureaus my performance of this agreement and to answer any questions about their credit experience with me. I authorize Keystone to release this application to my bank in order to obtain a bank reference. See future billing statements for important data.
*If a Business Entity requesting credit has less than $25 million in gross sales in the prior year, a personal guarantor will be required. Please indicate the name of the personal guarantor.

*Please read carefully: By signing as Personal Guarantor I am agreeing to be personally responsible for payment of all amounts billed on the accounts established on this credit application.
NAME OF 1ST PERSONAL GUARANTOR:*
NAME OF 2ND PERSONAL GUARANTOR:
PERSONAL GUARANTOR TITLE:
PERSONAL GUARANTOR TITLE:
SOCIAL SECURITY NUMBER OF GUARANTOR:*
SOCIAL SECURITY NUMBER OF GUARANTOR:
DATE OF BIRTH:*

MonthDayYear
Date
DATE OF BIRTH:

MonthDayYear
Date
SIGNATURE:*

Clear
SIGNATURE:

Clear
DATE:*

MonthDayYear
Date
DATE:

MonthDayYear
Date
Please submit a copy of your most recent financials for the business entity.*

FINANCIALS ENCLOSED
UPLOAD FINANCIALS:

Cancelof
Application will not be processed without signature and legibly printed name. Incomplete applications will be returned. Signature indicates you have read and agree to all terms and conditions.
APPLICANT 1 NAME:*
APPLICANT 1 TITLE:*
APPLICANT 1 SIGNATURE:*

Clear
DATE:*

MonthDayYear
Date
APPLICANT 2 NAME:*
APPLICANT 2 TITLE:*
APPLICANT 2 SIGNATURE:*

Clear
DATE:*

MonthDayYear
Date
APPLICANT 3 NAME:*
APPLICANT 3 TITLE:*
APPLICANT 3 SIGNATURE:*

Clear
DATE:*

MonthDayYear
Date
ATTACH OTHER DOCUMENTS:

Cancelof
NO REPLY
example@example.com
Should be Empty:

AUTHORIZED ACCOUNT USERS