Organic Produce Co-op Registration
Form
Name:
______________________________________________________________________________
Address:
_____________________________________________________________________________
______________________________________________________________________________
Phone
Number(s): ___________________________________________________________________
Email
Address:_______________________________________________________________________
Credit
Card Number:_________________________________________________Exp.__________
Signature:_____________________________________________________Date:_________________
If you would like your
registration fee to be charged to this credit card check here:
Emergency
Pick Up Contact (in case you are unable to pick up for any reason):
Name:__________________________________Phone:_______________________________________
Please
circle which options suit your needs:
1)
Produce Pick Up: Weekly Every Two Weeks Once a Month
2)
Produce Contents: Fruits Only Vegetables Only Fruits & Vegetables
3)
Package Size: Small ~10 lbs ($25) Medium ~20lbs ($45) Large ~30lbs ($65)
4)
Payment: Weekly Monthly
Quarterly
4)
Any fruits or veggies you are allergic to or can’t eat due to a special
diet? Please list below:
Please
mail this form along with your one time, non-refundable membership fee of
$30.00 to:
Urban Organics
5325 Fairmont St
Jacksonville, FL 32207
Please make all checks and money
orders payable to: Urban Organics LLC