NEIC C/D Share Purchase Form
This form is for existing NEIC members who wish to purchase additional co-op stock through the C/D share program. If you are not already an NEIC member, please join at www.neic.coop/membership.
All members must receive the C/D Share Program Prospectus before purchasing. Please e-mail info@neic.coop if you have not yet received a copy of this document.
Member Name
*
First Name (or Corporation Name)
Last Name
Member Name #2 (if joint membership)
First Name
Last Name
E-mail
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
The purchaser(s) is/are
*
Corporation
Single person
A married couple (community property)
Joint tenants in common
A married person as his/her separate property
Purchase Agreement
*
By signing this agreement, I acknowledge that NEIC is relying on my representations in complying with its obligations under federal and state securities laws. Purchaser makes the following representations: 1. I have relied only on the information contained in the Investment Prospectus provided by NEIC in evaluating this offering. 2. I have had an opportunity to review any documents that I requested from NEIC to verify the information contained in the Investment Prospectus. 3. I am a fully-paid member-owner of the Northeast Investment Cooperative and a resident of Minnesota. 4. I have the knowledge and experience to adequately evaluate this investment. 5. I realize that these shares are sold pursuant to an exemption from federal and state securities laws, and that they are not freely transferable. 6. I understand that NEIC is a start-up cooperative with a volunteer board. 7. I understand that this investment is speculative and involves a substantial degree of risk, including, but not limited to, the risk factors identified in the accompanying prospectus. 8. I understand that if the co-op were to fail or fold, my C or D-share investment would be subordinate to any secured interests in NEIC’s assets held by a bank or other lender.
Typed signature of member
*
Typed signature of member #2 (if joint membership)
Date
*
-
Month
-
Day
Year
Date Picker Icon
C shares purchased (at $500 each)
D shares purchased (at $5000 each)
Total share purchase cost
*
Payment method
*
Please send me an electronic invoice for payment via bank transfer.
I will mail a check to NEIC, PO Box 18082, Minneapolis, MN 55418.
For tax purposes, NEIC is required to have the Social Security number (or tax ID number) for all C/D-share holders. An NEIC board member will call you to confidentially request this information and enter it in our secure database.
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