Name on Account *

First Name

Last Name

Update name to:

We will update our records if different from what's currently on file.

First Name

Last Name

Preferred Phone Number *

(###)

###

####

Current Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Owner Name *

(Name in our system)

First Name

Last Name

Legal Name for Check: *

(Name on your bank account)

First Name

Last Name

Account Closure Date *

After this date, you will no longer receive your owner benefits and therefore forfeit your patronage refund. Note, it may take 2-3 weeks from your closure date before you receive your refund check.

MM

DD

YYYY

Phone *

(###)

###

####

Forwarding Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

We value your feedback. Please share the reason/s you're leaving the Co-op. *

Check all that apply.

Moving out of the area

No longer shopping at Co-op

Financial reasons

Dissatisfied with owner benefits (please explain)

Excess equity request

Other (please explain)

O. Fund Donation

Join date [if after 10/1/16, file by last name]:

MM

DD

YYYY

Shopper

Date on Check:

QB Check#