Equity Withdrawal Transfer and Name Change

APPLICATION FOR WITHDRAWAL OF EQUITY

Transfer and Name Change
Membership Name
Account Name you apply to withdraw equity from
Membership Number
Account you apply to withdraw equity from
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Transfer Membership:
Membership Name
Membership you want to transfer the equity to
Membership Number
Membership you want to transfer the equity to
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
SIN Number
The Co-op requires your Social Insurance Number (SIN) because the law requires us to report patronage allocations for income tax purposes
Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Name Change:
Old Name

First NameLast Name
New Name

First NameLast Name
Please attache the following Documents:

□ Proof of Name Change
Please attach here:

Cancelof
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