Membership Application

770 N High School Road, Indianapolis, IN 46214

PHONE: (800) 525-0272
MEMBERSHIP APPLICATION

Thank you for your interest in joining your 100% farmer-owned co-op!
APPLICANT INFORMATION
Applicant hereby agrees to purchase stock in the above cooperative by payment of cash, and thereby to become a member in the cooperative. One name per application please. This application for membership is to be recorded and patronage allocation made in the name of:
Which state are you an active agricultural producer in?
Unfortunately, you do not meet the criteria for Keystone Cooperative membership.

MEMBERSHIP APPLICATION

Thank you for your interest in joining your 100% farmer-owned co-op!
Please provide your total combined acreage owned and acreage rented:
Unfortunately, you do not meet the criteria for Keystone Cooperative membership.

MEMBERSHIP APPLICATION

Thank you for your interest in joining your 100% farmer-owned co-op!
Full Name:*
Date of Birth:*

MonthDayYear
Date
SSN or TIN:*
Mailing Address:*
City/State/Zip:*
County:*
Phone:*
E-mail:
example@example.com
Farm Location(s):
Years of Farming Experience:
Occupation (other than farming):
Primary Keystone Branch Serving You:*

FARM INFORMATION
Acreage Owned:*
Acreage Rented:*
Landlord Contact (Name & Phone):

Head/Acres:*

	Quantity
Swine
Corn
Beef
Beans
DairyCattle
Poultry
Other

CO-OP EXPERIENCES
Do you currently patronize Keystone Cooperative?*

YesNo
Do you currently patronize other Co-ops?

YesNo
Other Co-op Name(s):
Applicant account name(s):
Applicant account number(s):

MEMBER (Common) AGREES:
If my application for membership in this cooperative is approved, I hereby consent to take into account at their stated dollar amounts in the taxable year received by me, and in the manner provided in section 1385 (a) of the Internal Revenue Code, any distribution with respect to my patronage of or with this cooperative on and after the date on which I become a member of the cooperative, that are made in “written notices of allocation” as defined in Section 1388 of the Internal Revenue Code. The co-op has first lien on patron equity per our by-laws. Please initial:
Agree:*

Clear
Disagree:*

Clear
QUALIFICATIONS FOR MEMBERSHIP IN THIS COOPERATIVE:
a. The members of this cooperative shall be the holders of its voting common stock who are qualified to hold same in accordance with the provisions of the Articles of Incorporation and of the Bylaws, and who patronize and cooperate with this co-op.

b. Any person, partnership, corporation or association who or which is a producer of agricultural products, or who or which, by virtue of being a landlord or tenant, shares or has an interest in the production of agricultural products, and any association of such producers may become a member by patronizing this co-op and acquiring at least one share of its voting common stock, and may remain a member of this co-op so long as he or it is a producer, has an interest in the production of agricultural products or is an association of such producers and continues to patronize this co-op.

c. No person, partnership, corporation or association shall be deemed to be a patron of this co-op if he or it has not patronized or done business with this co-op during the immediately preceding three fiscal years.

I hereby certify that I meet the qualifications for membership in this cooperative, as set forth above, and submit herewith, in payment in full for one (1) share of cooperative voting common stock to be issued in my name, the sum of $5.00. Cash or check is accepted. Applications are submitted to the Board of Directors for approval after payment is made. Payment may be made at your local branch or please mail to:

Keystone Cooperative
Attn: Membership
770 North High School Rd.
Indianapolis, IN 46214

If you pay by check, please anticipate that your check will not clear until after the next board meeting.
Applicant Signature:*

Clear
Date:*

MonthDayYear
Date
No reply
example@example.com
Should be Empty:

MEMBERSHIP APPLICATION

APPLICANT INFORMATION

MEMBERSHIP APPLICATION

MEMBERSHIP APPLICATION

FARM INFORMATION

CO-OP EXPERIENCES

MEMBER (Common) AGREES:

QUALIFICATIONS FOR MEMBERSHIP IN THIS COOPERATIVE: