Date *

MM

DD

YYYY

Owner 1 *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Owner Equity Withdrawal *

I hereby request to withdraw my VFC ownership.

What would you like us to do with your owner equity? (choose one) *

Please donate my equity to the Viroqua Food Co-op Cooperative Community Fund, 501(c)3.

Please mail my equity refund to the address listed above.

Voluntary Survey

I am withdrawing my equity from the VFC for the following reasons (check all that apply):

Leaving the area

I no longer shop at the Co-op

Other