Credit Application

APPLICATION FOR OPEN ACCOUNT CREDIT TO

N. KOHL GROCER COMPANY

(d/b/a)

KOHL WHOLESALE (“Kohl”)

130 Jersey Street

P O Box 729

Quincy, IL 62306-0729 217-222-5000

Toll Free: MO/IA 800-245-5645 IL 800-222-5645

Accounting Fax: 217-222-5035

Website: www.kohlwholesale.com

Email: c[email protected]

Incomplete and illegible applications will not be processed

Sales Rep #:_______ Date:__________________

Account #:______________________

APPLICANT/CUSTOMER INFORMATION

Name:

Trade Name

(If Different)

Address:

City, State, Zip: County:

Phone Number: ( ) Fax Number:( )

Email Address:

Federal Tax I.D. Number/Social Security Number:

ORGANIZATIONAL STATUS

(check one)

‘ Corporation ‘ Limited Liability Company ‘ Partnership ‘ Sole Proprietorship ‘ Other_______________

If Corporation or LLC, State of Organization: Year:

President or Manager:

Type Of Business: (Restaurant, School, Nursing Home, Tavern, Catering, etc.)

Length of time in business:

Hours of Operation: Open Close

BILLING INFORMATION

(if different from above)

Name: Account #:

Address:

City, State, Zip:

Phone Number: ( ) Fax Number: ( )

Accounts Payable Contact:

SHIPPING INFORMATION

(if different from above)

Name:

Address:

City, State, Zip:

Phone Number: ( ) Alternative Phone Number: ( )

LIST INFORMATION FOR ALL INDIVIDUAL CUSTOMER OWNERS/PRINCIPALS

Name: Title:

Home Address:

City, State, Zip: Cell Phone Number:

Home Phone Number: ( ) Social Security Number:

Driver’s License Number: State: Date of Birth:

Name: Title:

Home Address:

City, State, Zip: Cell Phone Number:

Home Phone Number: ( ) Social Security Number:

Driver’s License Number: State: Date of Birth:

Name: Title:

Home Address:

City, State, Zip: Cell Phone Number:

Home Phone Number: ( ) Social Security Number:

Driver’s License Number: State: Date of Birth:

Name: Title:

Home Address:

City, State, Zip: Cell Phone Number:

Home Phone Number: ( ) Social Security Number:

Driver’s License Number: State: Date of Birth:

MORTGAGOR OR LESSOR (check one) ‘ Owned ‘ Leased ‘ Rented

If owned, the name, address and telephone number of the mortgagor (if any):

Name:

Address:

IF leased or rented, the name, address and telephone number f the lessor/landlord:

Name:

Address:

CUSTOMER BANK REFERENCES

Name of Bank: Account #:

Address: Phone #:

City, State, Zip: Fax #:

Name of Bank: Account #:

Address: Phone #:

City, State, Zip: Fax #:

BUSINESS CREDIT REPORT AUTHORIZATION

Customer and Guarantor(s) authorize Kohl to obtain a business credit report for each of them. Customer and Guarantor(s)

understand that Kohl intends to use the credit report to confirm business addresses, verify banking and other credit information,

and evaluate whether sufficient income is available to support Customer’s Application for Open Account Credit. Any business

credit reports will only be used by Kohl in processing the Application and all credit reports will be retained on file by Kohl along

with all other Application documents. This Authorization will remain in full force and effect if Kohl approves this Application and

sells product to Customer on an open credit account until sixty (60) days after such Customer’s balance is paid in full or

Customer’s last purchase from Kohl, whichever is later. Otherwise, this Authorization shall expire one hundred twenty (120)

days from the date this Application is signed.

CUSTOMER TRADE REFERENCES

(companies with whom customer has established credit)

Name: Account #:

Address: Phone #:

City, State, Zip: Fax #:

Name: Account #:

Address: Phone #:

City, State, Zip: Fax #:

Name: Account #:

Address: Phone #:

City, State, Zip: Fax #:

TERMS AND CONDITIONS

By signing and submitting this application, Customer agrees to the following terms and conditions. Kohl is authorized to contact

any and all of the owners, principals and references listed above regarding Customer’s credit standing. If the application for

open account credit is approved, Customer agrees to pay its account in full within the time and according to the terms specified

in each invoice issued to Customer. If this account is not paid as specified: (a) interest at the rate of one and three quarter

percent (1.75%) per month shall accrue on the unpaid balance; (b) Kohl reserves the right to withhold any shipments or further

credit, or impose additional terms as a condition of any further credit; (c) Kohl may pursue all available legal remedies against

Customer and any Guarantor; and (d) Customer and Guarantor(s) consent to personal jurisdiction in any state or federal court

having venue in Adams County, IL; and (e) all costs and expenses incurred by Kohl in collecting any amounts due, including

reasonable attorney’s fees, will be included in the amount due from and paid by Customer and Guarantor(s). Customer agrees

to waive all claims against Kohl, and hold harmless and defend Kohl from any injuries or damages resulting from or related

to any failure of customer’s premises, including all electrical, communications, fiber optics, data processing, telephone and

other utility lines connected to customer’s premises, to comply with applicable building and safety code requirements.

In the event of any changes in ownership or legal structure of the applicant, I/We agree to notify Kohl Wholesale in writing of

the changes by certified mail, mail return receipt requested. Kohl Wholesale shall not be affected by such changes until receipt

of this written notification of these changes from the applicant.

L X

Signature Title Date

STATE SALES USE TAX CERTIFICATE (check applicable box)

This is to certify that merchandise purchased by the undersigned from N. Kohl Grocer Company, (d/b/a) Kohl Wholesale

and Subsidiaries, Quincy, Illinois, for use in their operation has the following State Sales Use Tax Status.

‘ Sold to the public, on which we collect and remit Retail Sales Tax (Most Common)

Our State Sales Tax Number is:________________________________________________

State of:___________________________________________________________________

Items Exempt: FOOD PRODUCTS, Other:________________________________________

‘ Exempt from State Sales Tax

Exempt on the following basis:_________________________________________________

State Exemption #:__________________________________________________________

State of:___________________________________________________________________

(Attach a copy of your Exemption Certificate or Letter from your State)

‘ We hereby request N. Kohl Grocer Company, Inc., (d/b/a) Kohl Wholesale,

and its Subsidiaries to add Sales Use Tax to their invoices for such products used in our

operation on which no Sales Tax Exemption is granted by the state on which we do not

Collect or Remit Sales Tax.

Name in which Retail Sales Tax/Exemption Certificate is issued

Address City, State, Zip

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Authorized Signature (Owner/Principle) Date

GUARANTY

I, _____________________________and ____________________________, For and in consideration of the extension

of credit to ______________________________________________________(Customer), the undersigned Guarantor(s)

agrees to the foregoing Application, including, but not limited to, the Business Credit Report Authorization the Terms and

Conditions, and all Addendums (if any), and guarantee full and prompt payment of any obligation of the Customer owed

to Kohl, whether now existing or herein after incurred, and further agrees to pay on demand any sum which is due from

the Customer to Kohl whenever the Customer fails to pay same. This guaranty shall be an absolute, continuing and

irrevocable guaranty for such indebtedness of the Customer. The undersigned expressly waives presentment, demand,

protest, notice of protest, dishonor, diligence, notice of default or nonpayment, notice of acceptance of this guaranty,

notice of the extending of any guaranteed indebtedness already or hereafter contracted for by the Customer, notice of

any modification or renewal of any credit agreement evidencing the indebtedness hereby guaranteed, notice of any

renewal or indebtedness hereby guaranteed and to all renewals or extensions of such indebtedness. The undersigned

further waives any right to require Kohl to proceed against or make any effort at collection of the guaranteed indebtedness

from the Customer or any other party liable for such indebtedness. If the guaranteed indebtedness is not pay by the

undersigned when due, and this guaranty is placed in the hands of an attorney for collection, or suite is brought thereon,

or it is enforced through any judicial proceeding whatsoever, the undersigned shall also pay all reasonable attorneys’ fees

and court costs incurred by Kohl as part of the guaranteed indebtedness. In the event more than one party executes this

Guaranty as a Guarantor, then each Guarantor, agrees to be jointly and severally liable for the guaranteed indebtedness

and, in all instances herein, the singular shall be construed to include the plural.

L X

Guarantor Signature Print Name Date

L X

Guarantor Signature Print Name Date

Witness Signature Salesperson Guaranty Date

ACCOUNTING USE ONLY

Terms: Approved By: Date:

Revised Terms: Approved By: Date:

KOHL WHOLESALE PRIVACY PROTECTION POLICY

We at Kohl Wholesale value your patronage and want to maintain your confidence in our business relationship. With this in

mind, we have formulated the following principles and guidelines regarding the collection, use and security of personal

information you provide to us. INFORMATION COLLECTION During our relationship, we may collect and use nonpublic

personal information about you from public records, m ar ke t r es ea rc h, con s um e r r ep or ti ng a ge nc ie s , m e d ical service providers,

transactions with us, our affiliates or others; information provided from you on applications, claim forms or other forms; and

information obtained from our agents. We strive to keep this information accurate and up-to-date. If you discover this

information is incomplete, inaccurate or not current, please notify us immediately at the address or telephone number listed

on this application. Our employees’ limited access to customer information is based on job function. We educate our

employees so they understand the importance of customer confidentiality and privacy. Employees who disregard their privacy

responsibilities are subject to discipline. To better service your needs, your nonpublic personal information may be shared.

All of our companies work together to provide the services you may want. By sharing information about your accounts and

relationships among companies, we can serve you more efficiently and make it easier for you to do business. We do not

disclose any nonpublic personal or business information about our customers or former customer to anyone, except as

permitted by law. We may disclose information to third parties when we believe it is necessary to conduct our business or

where disclosure is permitted by law. Information may be disclosed to others who assist us in providing business services and

or assisting us in processing transactions which you have requested or initiated. Information may also be disclosed for audit

purposes to help us prevent fraud to law enforcement and regulatory agencies, to consumer reporting agencies or as otherwise

permitted by law.

FOR OFFICE USE ONLY

Pricing

Meat Produce Level Allowances

Do you want any special sheets?

How do you want the special sheets? (Check one) ‘ Mail ‘ Faxed ‘ Email

Statement Print Day: ‘ Monday ‘ Thursday

Preferred Delivery Time (4 hour window required): 1

Preference 2

Preference

Preferred Delivery Day(s) (circle): M T W TH F

Estimated Weekly Purchases: $ Estimated $ per drop: $

SPECIAL INSTRUCTIONS:

revised 05-08-2018 ref: (blr) credit application 4 pages

Account #: