Cash Application - Middleton Farmers Cooperative

Name 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 1

City

State

Zip Code

Terms & 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.

Signature of Patron

Clear Signature

Date

Print Name

Do you want cash member cards, you can use at the convenience store?

Yes
No

Cash Member Cards Order Form

Chose all that apply:

I would like a card kept behind the counter at Pleasant View Cenex
I would like a card kept behind the counter at University Ave Cenex
I would like Profit Point cards for me to carry on me for inside sales

If so, how many?

If you are ordering profit point cards, would you like to PICK THEM UP or HAVE THEM MAILED

PICK THEM UP
HAVE THEM MAILED

Mailing address:

Address Line 1

City

State

Zip Code

Phone # 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

Drag & Drop Files, Choose Files to Upload