NAME __________________________________________________

ADDRESS __________________________________________________

PHONE __________________ E-MAIL ____________________

DEPOSIT __________________ # ADULTS IN HSHOLD ___________

--Adult includes anyone over 12 years old.

--Initial deposit is $15 for the first adult plus $5 for each additional adult

--The deposit is refundable upon withdrawal from the co-op.

Bills must be paid when orders are picked up. Members with outstanding debt will not be allowed to re-order through the co-op until the debt is paid in full. An outstanding debt for more than two consecutive months, or repeated late payments will be grounds for termination from the co-op.

Members are expected to fulfill their work commitments as designated by the co-op. Repeated failure to do so will undermine the efficiency of our cooperative effort and will be grounds for termination from the co-op.

-----------------------------------------------------------------------------------------------------------

I have read and understand the above requirements and agree to fulfill my responsibilities as a member of the Pilsen Food Co-op.

Signed _____________________________________

Deposit Received ____________________________

Date _______________________________________