Become a Member Form

USE THIS FORM TO RENEW YOUR MEMBERSHIP

APPLICANT INFORMATION

Applicant Name (Individual or Business Entity)*

Authorized Representative (if Business Entity)*

Home Phone

Mobile Phone

Work Phone

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Enter Email Confirm Email

Date of Birth*

Is this a joint application?*

Yes
No

SPOUSE INFORMATION IF JOINT APPLICATION

Name

First Last

Email

Enter Email Confirm Email

Mobile Phone

Date of Birth

TYPE OF APPLICANT

(Select appropriate circle and include applicable identifying number)

TYPE OF APPLICANT*

Individual or Sole Proprietorship

social security # or tax id. #

Partnership

tax id. #

LLC or LLP

tax id. #

Corporation

tax id. #

Other Entity

tax id. #

OCCUPATION

(Select appropriate circle)

OCCUPATION*

If Other, please specify

FARM OPERATIONS

Are you currently farming?*

Yes
No

This will help us to better serve you.

Indicate the crops you generally grow:

Corn
Soybeans
Hay
Vegetables and/or Fruits
Organic Crops
Specialty Crops

Indicate types of livestock you raise:

If Other, please specify

TERMS AND CONDITIONS

Consent*

I agree to the terms and conditions.

I certify: (1) that all the information contained in this application is true and correct to the best of my knowledge; (2) that I have read, understand and accept the stated terms and conditions applicable to this agreement which are set forth on the reverse side of this agreement; and (3) that I have been provided with all of the information that I believe to be necessary for a full understanding of the Cooperative and for becoming a Member.

Signature of Applicant*

Date*

Signature of Spouse

(only if for a joint membership)

Date

FEES

Initial Membership Investment	$250	Payable at the time of application submission
Annual Fee	$25	Payable by March 31 of each year

Initial Membership Investment

Price: $250.00

Annual Membership Renewal Fee

Price: $25.00

Late Fee

Price: $5.00

Total

$0.00

BILLING INFORMATION

Name*

First Last

Email*

Address*

Use address from the Applicant Information section

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

APPLICANT INFORMATION

SPOUSE INFORMATION IF JOINT APPLICATION

TYPE OF APPLICANT

OCCUPATION

FARM OPERATIONS

TERMS AND CONDITIONS

FEES

BILLING INFORMATION