Bike Farm 2011 Membership Form

2780 230th St, Cushing, WI 54006 * (715) 648 5773 * bikefarm@yahoo.com

Household:
Name(s):
Address:
Phone: _________________ Email: No. of people sharing this box (if any)

Number of Newsletters needed for this share _____ or Total No. of Newsletters for this drop

Delivery Address (include zip code):

Brief Description of delivery site and cross street to help us find you! (i.e. 2 story gray house on NE corner of Lexington
and Grand.)

Where should we leave the box?

Please circle the rate that fits your membership.

Rates

Individual Delivery $600

(One share to one address)

Group Site Delivery $550

(Three shares or more to one address)

On Farm Pick-up $500

Individual Half-Share $450

(One half-share to one address)

Group Half-Share $400

(Three shares or more to one address)

On Farm Pick-up $350

*Payment plans can be arranged for any prospective members

Amount Enclosed: ________________

(Please make check out to the Bike Farm. One check per share is preferred.)

-----------------------------------------------------FOR OFFICE USE ONLY------------------------------------------------------------

DATE _________ CHECK NO. ________ AMT. PAID__________ MEMBER NO._________