Equity Withdrawal Moved away

APPLICATION FOR WITHDRAWAL OF EQUITY

Moved away
In order to be eligible to apply for equity withdrawal on this form you need to be moved out of the trading area of Evergreen Co-operative Association.
Membership Name
Account Name you apply to withdraw equity from
Membership Number
Account you apply to withdraw equity from
New Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
- Please attache the following Documents:
  
  □ Legal document proofing new address
- Please attach here:
  
  Cancelof
- Payout:
- The Co-op respects your privacy. The personal information in this form will be used to communicate with you and to administer the Equity and Cash Back Program. The Co-op requires your Social Insurance Number (SIN) because the law requires us to report patronage allocations for income tax purposes. Your date of birth is used to administer the overage policy with respect to the Equity and Cash Back Program. I understand that by signing this application form, I am consenting to the collection of my personal information and to its use for the stated purposes.
- Signature
- MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Should be Empty:

APPLICATION FOR WITHDRAWAL OF EQUITY