Combined Credit Card Authorization Form

Update an existing card:(Required)

Yes

Your Email Address(Required)

Email Address Confirm Email Address

I, (Customer Name):(Required)

Authorize (Store Name and Address):(Required)

to charge the credit account indicated below for deliveries made per my telephone, mail or automatic fill program request. This payment form will remain in force until the expiration date of the credit account listed below or until I notify the store at the above store address, by mail.

Mark the appropriate option for the payment tyle:(Required)

VISA

MasterCard

Discover

AMEX

Reason for Credit Card Authorization:(Required)

If Agricultural Account is selected, please fill out forms 3 and 4 on the website as well.

Name as it appears on card(Required)

First Middle Last

Mail Address(Required)

Street Address Address Line 2 City State ZIP Code

Physical Address (if different from mailing address)

Street Address Address Line 2 City State ZIP Code

Customer Phone #(Required)

Credit Card Card Number(Required)

Exp. Date(Required)

Signature(Required)

First Last

Entering your first and last name provides an electronic signature to this application.

Signature(Required)

Touch Sign Here

Decline charges to the above. Listed account will be billed to you. Payment in full is expected within 30 days from the date of the bill. If payment is not received within that time, southern states reserves the right to charge interest at a rate of 18% per annum, as well as reasonable attorneys fees in the event litigation or other collection efforts are required.

Authorized Users

I hereby authorize the following individuals to sign my credit card account, listed above on my behalf of products and or services purchased or ordered per telephone request, mail, request, or in person, made by myself, or by person authorized below.

Authorized:

(1) Name

First Last

(1) Signature

First Last

(1) Account Holder

First Last

Date

(2) Signature

First Last

(2) Account Holder

First Last

(2) Name

First Last

Date

(3) Name

First Last

(3) Signature

First Last

(3) Account Holder

First Last

Date

Note: If any authorized user is no longer authorized to place charges, the cardholder must cross out the authorized users name, sign, and date the form opposite that name that has been stricken.

Disclosure Statements(Required)

Check If You Agree:

Please Read Carefully Before Signing
I/We certify that the foregoing information as well as the information on page 2 have been supplied truthfully, accurately, and voluntarily and therefore authorize Southern States ("Creditor") to Investigate my/our creditworthiness through any credit bureau or by another reasonable means, including direct contact with past and present creditors. I/We also authorize banks and other financial institutions to give information to the named Creditor in connection with this transaction about my/our savings and checking accounts and loans. The undersigned hereby authorizes and consents to Lender(s) listed in Section 4 releasing financial information including a copy of my/our most recent financial statement to Creditor of such material. If credit is extended as a result of this application, I/we agree to make payment promptly in accordance with the Creditor's usual terms. I/We have read and acknowledge receipt of a copy of this application and attached form(s) explaining any credit plan applied for above.

The undersigned hereby consent(s) to Creditor's use of a non-business consumer credit report on the undersigned in order to further evaluate the creditworthiness of the undersigned as principal(s) , proprietor(s) and/or guarantor(s) in connection with the extension of business credit as contemplated by this credit application. The undersigned hereby authorized Creditor to utilize a consumer credit report on the undersigned from time to time in connection with the extension or continuation of the business credit represented by this credit application. The undersigned as [an] individual(s) hereby knowingly consent to the use of such credit report consistent with the Federal Fair Credit Reporting Act as contained in 15 U.S.C. @ 1681 et seq.

CAUTION - IT IS IMPORTANT THAT YOU THOROUGHLY READ THE APPLICATION BEFORE YOU SIGN IT. *
I Agree
Disclosure Statements

Regular Plan Credit Policy
The Credit Policy of the Creditor shall be extend 30 days' accommodation credit to approved customers. No customer shall be extended additional credit if any portion of the account is over 60 days past due. At the discretion of the Creditor, new credit will only be extended after the customer pays the past due portion of the account in full.

Regular Plan Terms
1. Purchases paid within 30 days of billing statement date are not subject to the FINANCE CHARGE.
2. Purchases unpaid as of the second billing statement following the purchase(s) are subject to a monthly FINANCE CHARGE on the Previous Balance less any payments and credits appearing on Statement
3. The period allowed for payment is 30 days from the first billing statement rendered following the charge. Charges unpaid after that time are in default.
4. If any check or other payment instrument on your account is dishonored for any reason upon presentment, you agree to pay the Return Check Fee indicated in the table below to the extent permitted by law.
5. If this account is referred to an Attorney or Collection Agency for collection, the Customer agrees to pay, in addition to the balance due and the applicable FINANCE CHARGE, the maximum Attorney's fees, Collection Agency fees, and Court costs permitted by State law.
6. The Creditor has the right to reduce the Credit Line and/or withdraw credit privileges at any time without prior notice, except as otherwise provided by law.
7. Customer and Creditor may terminate this agreement at will as to future purchases. Customer certifies that the information given on this application is given to obtain Credit and is true and correct.
8. SEE THE TABLE BELOW for the FINANCE CHARGES; INTEREST RATES; COLLECTION COSTS & FEES; that apply for commercial transactions in each state.

Extended Plan Terms
1. Extended Plan Terms are credited at the discretion of the Creditor to approved creditworthy Customers. Only goods/services directly related to, or used in, production or commercial agriculture may be purchased by Customer(s) on Extended Plan Terms.
2. The Creditor will assign a maximum credit amount ("Credit Line") to the Customer from time to time. As a condition to granting credit approval, Creditor, in its sole discretion, may require Customer to execute any or all of the following documentation (Credit Application, Credit Line Note; Security Agreement; UCC Financing Statements; Notifications to Purchasers of Crops; Goods; and Farm Products; Mortgages; Deeds of Trust; Milk Assignments, US Government Payments, etc) in favor to the Creditor.
3. Payment DUE DATES and AMOUNTS DUE will be determined by Creditor and are payable on DEMAND; and if no demand is made, then on or before December 21st of each year.
4. Customers purchase(s) under Extended Plan Terms are subject to INTEREST CHARGES and/or FINANCE CHARGES to the extent permitted by State law. INTEREST shall be computed on the unpaid average daily principal balance outstanding during the term of the Note.
5. If any check or other payment instrument on account is dishonored for any reason upon presentment, you agree to pay the Return Check Fee indicated in the table below to the extent permitted by law.
6. If this account is referred to an Attorney or Collection Agency for collection, the Customer agrees to pay, in addition to the balance due and the applicable FINANCE CHARGE. the maximum Attorney's fees, Collection Agency fees, and Court cost permitted by State law.
7. The Creditor has the right to reduce the credit line and/or withdraw credit privileges at any time without prior notice, except as otherwise provided by law.
8. Customer and Creditor may terminate this agreement at will as future purchases. Customer certifies information given on application is given to obtain credit and is true and correct.
9. SEE THE TABLE BELOW for the FINANCE CHARGES; INTEREST RATES; COLLECTION COSTS & FEES; that apply for commercial transactions in each state.

Table: Commercial Rates For the State of VA
Financæ Charge/Interest (Annual): 18%
Finance Charge/Interest (Per Monül): 1.50%
Minimum Finance Charge: $0.50
Returned Check Fee (No Finance Chame): $50

In Case Of Errors Or Inquiries About Your Bill

The Federal Truth in Lending Act requires prompt correction of billing mistakes.
1. If you want to preserve your rights under the Act, here's what to do if you think your bill is wrong or if you need more information about an item on your bill:
a. Do not write on the bill. On a separate sheet of paper, write (you may telephone your inquiry but doing so will not preserve your rights under this law) the following:
i. Your name and account number (if any)
ii. A description of the error and an explanation (to the extent that you can explain) why you believe it is an error. If you only need more information, explain the item you are not sure about and, if you wish, ask for evidence of the charge such as a copy of
the charge slip. Do not send in your copy of a sales slip or other documents unless you have a duplicate for your records.
iii. The dollar amount of the suspected error.
iv. Any other information (such as your address) which you feel will help the creditor identify you or the reason for your complaint or injury.
b. Send your billing error notice to the address on your bill which is listed after the words: "Send Inquiries To:" or similar wording. Mail it as soon as possible, but in any case, early enough to reach the creditor within 60 days after the bill was mailed to you. If you authorized your bank to automatically pay from your checking or savings account, any credit card bills from that bank that you think is wrong must be noticed by mailing your billing error notice so the creditor receives it within 16 days after the bill was sent to you. However, you do not have to meet this 16 day deadline to get the creditor to investigate your billing error claim.

2. The creditor must acknowledge all letters pointing out possible errors within 30 days of receipt, unless the creditor is able to correct your bill during that 30 days. Within 90 days after receiving your letter, the creditor must either correct the error or the creditor has explained the bill, the creditor has no further obligation to you even though you still believe there is an error, except as provided in paragraph 5 below.

3. After the creditor has been notified, neither the creditor nor an attorney nor a collection agency may send you collection letters or take other collection action with respect to the amount in dispute: but periodic statements may be sent to you, and the disputed amount can be applied against your credit limit. You cannot be threatened with damage to your credit rating or sued for the amount in question, nor can the disputed amount be reported to a credit bureau or to creditors as delinquent until the creditor has answered your inquiry. However, you remain obligated to pay the parts of your bill not in dispute.

4. If it's determined that the creditor has made a mistake on your bill, you will not have to pay any finance charges on any disputed amount. If the creator has not made an error, you may have to pay finance charges on the amount in dispute, and you will have to make up any missed minimum or required payments on the disputed amount. Unless you have agreed that your bill was/is correct, the creditor must send you a written notification of what you owe; you must be given the time to pay which you normally are given to pay undisputed amounts before any more finance charges or late payment charges on the disputed amount can be charged to you.

5. If the creditor's explanation does not satisfy you and you notify the creditor in writing within 10 days after you receive their explanation that you still refuse to pay the disputed amount, the creditor may report you to credit bureaus and other creditors once the matter between you and the creditor has been settled, the creditor must notify the credit bureaus and other creditors to whom you were reported as being delinquent of the subsequent resolution. *

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Combined Credit Card Authorization Form

Combined Credit Card Authorization Form

Authorized Users