Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I am signing up to be an affiliate member of Co-op Power to support Co-op Power's work and to participate in some of Co-op Powers group purchasing programs. I agree to pay $25 each year. I understand that this is not a full membership in Co-op Power and that I am not an owner of this cooperative. I am not eligible for member discounts, voting privileges, or patronage refunds . I understand that I am free to join Co-op Power as a full member at any time. *

I agree

I cannot agree at this time

Date *

MM

DD

YYYY