Membership Application Form

I hereby apply for a Regular membership in the Breadroot Cooperative, hereinafter referred to as the Cooperative.
Name:
Address:
Phone:
Occupation/Skills:
Is this a joint membership?
Other person's name:
Occupation/Skills:
Other family members or dependents (including those of the joint member) authorized to purchase goods through this membership:
Share payment: A purchase of two shares of Class A Common Stock is required to initiate membership, at the price of $10.00 per share. Membership is extended by the purchase of two additional shares every twelve months until 40 shares are purchased. This constitutes a subscription payment of membership dues.
Do you wish to pay by subscription?
E-mail Address Agreement: By submitting my e-mail address to the Cooperative, I understand that the Cooperative agrees to use my address only for official notices of cooperative business (such as meeting announcements, financial statements, and patronage credits), and for replies to messages that I've posted to the Cooperative. In turn, I agree to use the Cooperative’s e-mail address only for necessary communications with the Cooperative.
E-mail Address:
I have read this application and understand its terms. This application is tendered on the condition that the Cooperative will purchase food and other merchandise and make it available to me at the price set by the Cooperative, and that I will agree to the terms and conditions of membership as established in the bylaws of the Cooperative. I have been given a copy of the bylaws, and I have had an opportunity to read them before signing this application.
Signature/Date:
(If joint member) Signature/Date:
Approval Date :
# Shares:	Member #:

Print and mail to:
Breadroot Cooperative, 802 Mt. Rushmore Road, Rapid City, SD 57701-3603