Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 2Cash Only - Membership Account Application Are you a consumer or a business? *ConsumerBusinessEmail Address *NextName of Patron (Legal IRS Name) *FEIN *Enter only numbers; do not enter spaces or hyphens, or other special characters.SSN *Enter only numbers; do not enter spaces or hyphens, or other special characters.Date of Birth *Phone *Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutDriver License Number (only for check payments)Please note: If cashier does not recognize you at the time of sale they will ask for identification in order to accept your check payment. This policy is necessary in order to assist in fraud prevention. It is a safeguard for you and the CO-OPEXP dateTerms & Conditions *I have read and agree to Consent to Declaration of Patronage Refunds listed below.Consent to Declaration of Patronage Refunds By signing this agreement, I hereby consent to include in my gross income (or the gross income of the entity that I sign this form on behalf of), as now or hereafter provided in the federal income tax laws, the stated dollar amount of each written notice of allocation which I or it receives from the Middleton Co-op Company, with respect to my or its patronage occurring during the current and all subsequent taxable years of this cooperative. This individual consent shall be revocable by me or it at any time in writing.LayoutSignature of Patron *Clear SignatureDate *LayoutPrint Name *Title *Do you want cash member cards, you can use at the convenience store? *YesNoCash Member Cards Order FormChose all that apply:I would like a card kept behind the counter at Pleasant View CenexI would like a card kept behind the counter at University Ave CenexI would like Profit Point cards for me to carry on me for inside salesIf so, how many?If you are ordering profit point cards, would you like to PICK THEM UP or HAVE THEM MAILED PICK THEM UPHAVE THEM MAILEDMailing address:Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone # to call when cards are ready:W-9 Forms All types of applications must also complete a W9 so we may pay you patronage. You can download W-9 forms here Here are instruction on how you can fill & sign the form using your gadget (Mobile & Desktop), No paper needed. How to fill & sign W-9 form on Mobile How to fill & sign W-9 form on PC/Desktop Upload your W-9 form here * Click or drag a file to this area to upload. Submit
