Free Range Food Co-op Membership Form

This application is intended for purchasing a Free Range Food Co-op gift of ownership for another person.

The gifter is the person purchasing the ownership gift. The giftee is the person receiving the ownership.

Please fill in all form fields. In addition, please indicate in the comment box at the bottom if you would like the ownership gift certificate mailed to you as the Gifter, or to the Giftee.

Gift ownerships must be paid in full at the time of purchase.

MEMBER EQUITY AGREEMENT

I agree to purchase one (1) share of Class A voting stock at $25.00, and three (3) shares of Class B equity stock at $25.00 each for a total of $100.00.

I understand that this application is subject to acceptance by the Board of Directors of the Co-op and that my membership is subject to the Bylaws and membership provisions.

A copy of the Free Range Food Co-op bylaws can be found at www.freerangefood.coop/bylaws

Name of Gifter (person giving gift)*

First NameLast Name

Street Address of Gifter*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Mailing Address of Gifter (if different)

Mailing Address

Mailing Address Line 2

CityState / Province

Postal / Zip Code

Email of Gifter (for ownership confirmation email)*

Phone Number of Gifter

Area CodePhone Number

Name of Giftee (person receiving gift)*

First NameLast Name

Names of additional adults in Household of Giftee (up to two)

Street Address of Giftee*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Mailing Address of Giftee (if different)

Mailing Address

Mailing Address Line 2

CityState / Province

Postal / Zip Code

Email of Giftee*

Phone Number of Giftee*

Area CodePhone Number

PAYMENT DETAILS

As with any investment, this ownership share is subject to risk. If the Co-op is unsuccessful, the Board of Directors will determine the distribution of remaining assets. In this unlikely event, every effort will be made to refund the paid portion of your owner equity share.

Upon choosing a payment option, you will be directed to PayPal to complete your transaction. A $4.12 administrative fee will be added to each transaction when paying by credit or debit card.

If you would prefer to pay by check, you can download the application here and mail it to PO Box 842, Grand Rapids, MN 55744.

PAYMENT OPTIONS*

Full Equity Share of $100 (plus $4.12 administrative fee)$104.12

Total $0.00

Please let us know if you would like the gift ownership certificate sent to you or directly to the giftee, along with any additional instructions.*

Gift Ownership Application