Agriculture Cooperative Member Information Form

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Farm Location (if different from home address)

What is the total size of your farmland (in acres or hectares)?

Which of the following best describes your main agricultural activity?

Other

Please specify the primary crops you grow (select all that apply):

Please specify the types of livestock you raise (select all that apply):

Do you currently own or have access to any of the following equipment? (Select all that apply)

How many years have you been involved in agriculture?

Have you previously been a member of an agricultural cooperative?

What is your preferred method of communication?

Is there any additional information you would like to share?