TRI-CITY CONSUMERS ACTION COOPERATIVE

NEW MEMBER INFORMATION SHEET

Welcome to Tri-City Co-Op!
To be eligible to join Tri-City Co-Op, an individual must be a resident of
New Hampshire and age 18 years or older. There are no fees for any of
the services we offer.
All information requested below is strictly confidential. Information for
statistical purposes only.
Todays Date: ___________________
Name (Please Print):
________________________________________________________
(Last Name)
Name)

(First

Address:
______________________________________________________________________
City: _________________________________State: NH
________________

Zip Code:

Telephone: (_____) ____________________ Email Address:

______________________
Age: _________ Birthdate: ______________ Gender:
M__________
(required)
(required)
(required)

F __________

Transportation Needed: ___________

Do you or have you ever served in the military?
_____________________
Emergency Contact Person: _________________________ Relationship: ________

as of 6/2014

Telephone Number: (____) _____________________ Cell #:

______________________
What are your goals?
________________________________________________________
________________________________________________________________________
__________
What are your interests?
______________________________________________________
________________________________________________________________________
___________
My signature below indicates I wish to become a member of
Tri-City Co-Op. I have read and understand the Tri-City Co-Op
House Rules and Values and will abide by these rules and
values. I acknowledge my obligation to respect the
confidentiality and privacy of fellow members, particularly
confidences shared in support groups.

_____________________________________
________________________________________
Signature
Date
For Staff Only:
Notes:
________________________________________________________________________
______
________________________________________________________________________
______________
________________________________________________________________________
______________

as of 6/2014