Membership - The Co-Op Farm & Garden

Fill out your membership form online or download the PDF below.

Cash Only Member Form

You can fill out your member form here or download it below.

Cash Only Member

Name *

Address

City

State/Province

Zip/Postal

Phone

Birthday:

Our Privacy Statement:

Clallam Co-op respects your privacy. We do not sell, rent, or give identifiable personal information regarding our customers to any third party. Information that you give to us is held with the utmost care and security.

Do you want to participate in the patronage payback?

Yes

REQUIRED INFORMATION

consent disclaimer

Members of the Clallam Co-op receive discounts in the store. Members may also receive a yearly dividend.
This dividend will be determined by the Board of Directors. *See page two(2) for explanation.*
The following information must be provided to meet IRS requirements.

Name as shown on account *

Taxpayer ID Number (SS# or EIN) *

Mailing Address *

Mailing Address

City

State/Province

Zip/Postal

Consent

I hereby consent to include in my gross income, as now or hereafter provided in the federal income tax laws, the stated dollar amount of each written notice of allocation which I receive from Clallam Cooperative, P.O. Box 608, Sequim, WA 98382, with respect to my patronage occurring during the current and all subsequent taxable years of this cooperative. This consent shall be revocable by me at any time if in writing.

Certification – Under penalties of perjury, I certify that (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and (2) I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding.

Certification Instructions – You must cross out items (2) above if you have been notified by the IRS that you are currently subject to backup withholding because of under reporting interest or dividends on your tax return. However, if after being notified by the IRS that you were subject to backup withholding you received another notification from the IRS that you are no longer subject to backup withholding do not cross out item (2) 

The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid backup withholding.

Signature *

Clear

Date *

Patronage Dividends

Patronage dividends allow us to strengthen our co-op so we can continue to serve our community now and in the future. Every year that the Co-op is profitable, our board will have the option of allocating dividends to members with some being retained as needed and some being distributed as deemed necessary.

Frequently Asked Questions

What is a Patronage Dividend?
When Co-ops have a surplus (a.k.a. profit) left over at the end of the fiscal year, the Board may vote to declare a share of the surplus to the members as distributable surplus. The surplus is allocated in direct proportion to a co-op member’s purchases in that fiscal year and that allocation is called a “Patronage
Dividend.”

Why does the Co-op retain a percentage of the Patronage Dividend?
The Board of Directors will determine the percentage of the Patronage Dividend that is to be retained. This is done on a yearly basis. This amount will be used by the Co-op to operate, to grow, and to achieve our Ends.

What will influence the potential amount of my Patronage Dividend in future years?
Your dividend is related to how much you shop at the Co-op, how successful we are as a business, and the expenses we face in a given year. The more successful we are, and the more you contribute to that success, the more you could get refunded.

How are my purchases recorded?
In order to record your purchase, the cashier asks for your member number before each transaction. All merchandise rung through under your number is recorded by our system.

Do I have to pay income taxes on my patronage dividend refund?
Patronage dividend refunds are not taxable income unless your purchases were for purposes other than personal use. If this is the case for you, please consult your tax advisor.

Cash Only Business Form

Cash Account - Business

Business Account Name *

Owner Name(s) *

Address

City

State/Province

Zip/Postal

Phone

Fax

Our Privacy Statement:

Clallam Co-op respects your privacy. We do not sell, rent, or give identifiable personal information regarding our customers to any third party. Information that you give to us is held with the utmost care and security.

Do you want to participate in the patronage payback?

Yes

REQUIRED INFORMATION

consent disclaimer

Members of the Clallam Co-op receive discounts in the store. Members may also receive a yearly dividend.
This dividend will be determined by the Board of Directors. *See page two(2) for explanation.*
The following information must be provided to meet IRS requirements.

Name as shown on account *

Taxpayer ID Number (SS# or EIN) *

Mailing Address *

Mailing Address

City

State/Province

Zip/Postal

Consent

I hereby consent to include in my gross income, as now or hereafter provided in the federal income tax laws, the stated dollar amount of each written notice of allocation which I receive from Clallam Cooperative, P.O. Box 608, Sequim, WA 98382, with respect to my patronage occurring during the current and all subsequent taxable years of this cooperative. This consent shall be revocable by me at any time if in writing.

Certification – Under penalties of perjury, I certify that (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and (2) I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding.

Certification Instructions – You must cross out items (2) above if you have been notified by the IRS that you are currently subject to backup withholding because of under reporting interest or dividends on your tax return. However, if after being notified by the IRS that you were subject to backup withholding you received another notification from the IRS that you are no longer subject to backup withholding do not cross out item (2) 

The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid backup withholding.

Signature *

Clear

Date *

Patronage Dividends

Patronage dividends allow us to strengthen our co-op so we can continue to serve our community now and in the future. Every year that the Co-op is profitable, our board will have the option of allocating dividends to members with some being retained as needed and some being distributed as deemed necessary.

Frequently Asked Questions

What is a Patronage Dividend?
When Co-ops have a surplus (a.k.a. profit) left over at the end of the fiscal year, the Board may vote to declare a share of the surplus to the members as distributable surplus. The surplus is allocated in direct proportion to a co-op member’s purchases in that fiscal year and that allocation is called a “Patronage
Dividend.”

Why does the Co-op retain a percentage of the Patronage Dividend?
The Board of Directors will determine the percentage of the Patronage Dividend that is to be retained. This is done on a yearly basis. This amount will be used by the Co-op to operate, to grow, and to achieve our Ends.

What will influence the potential amount of my Patronage Dividend in future years?
Your dividend is related to how much you shop at the Co-op, how successful we are as a business, and the expenses we face in a given year. The more successful we are, and the more you contribute to that success, the more you could get refunded.

How are my purchases recorded?
In order to record your purchase, the cashier asks for your member number before each transaction. All merchandise rung through under your number is recorded by our system.

Do I have to pay income taxes on my patronage dividend refund?
Patronage dividend refunds are not taxable income unless your purchases were for purposes other than personal use. If this is the case for you, please consult your tax advisor.

Credit Member Application - Individual

Credit Application - Member

Credit Limit

$500

Other

Credit Limit Requested Amount

Account Name

Your Name

SS#

Birthdate

Spouses Name

SS#

Birthdate

Address

City

State/Province

Zip/Postal

Drivers License #

Phone

Billing Address (if different than above)

City

State/Province

Zip/Postal

Present Employer

Years Employed

Position Held

Monthly Income

Other Income

Per

Source

Credit References

Name

City/State

Phone

Account Number

Balance

Name

City/State

Phone

Account Number

Balance

The following individuals are authorized to make charges to my account: (Please notify us immediately of any changes)

Do you want to receive your invoices via email?

Yes

Do you want to receive your statement via email?

Yes

Please provide your email:

Confirm Please provide your email:

Our Privacy Statement:

 Clallam Co-op respects your privacy. We do not sell, rent or give identifiable personal information regarding our customers to third parties. Information that you give us is held with the utmost care and security.

Our Terms

Our terms are “all sales are due and payable on or before the 10th of the month following date of purchase”. It further establishes a “finance charge” on all non-deferred balances more than 30 days old. The finance charge will be computed by a periodic rate of 1% per month or a .50 cent minimum. This is an “annual percentage rate” of 12% applied to all amounts and balances shown on your statement as being more than 30 days old. The closing date of each statement period (known as the billing cycle) will be shown on each statement. To avoid finance charges the “new charges” on each statement must be paid before the statement date for the next month. Our credit policy states those not meeting these terms will have their account placed on cash delivery (C.O.D.) until current. Any accounts with an outstanding balance exceeding 30 days will automatically become C.O.D. accounts, forfeit all member discounts, and remain such until the account is current. Collection proceedings may begin when an account exceeds 60 days.
I agree to pay the Co-op’s reasonable attorney’s fees in the event of non-payment and filing of suit to collect any balance I owe. Venue for suit shall be Clallam County, Washington, and I expressly waive all jurisdiction requirements of chapter 3.20 of the revised code of Washington as now or hereafter amended.
If you have questions, or desire further information, we will be pleased to have you come in and discuss them with us.

Acknowledgment

I acknowledge receipt and understand the “Notice to Customers” and agree to the payment terms and conditions. I submit the above facts as a basis for credit and warranty them to be true and accurate. I also certify that I am 18 years of age or older.

Signature

Clear

Date

Do you want to participate in the patronage payback?

Yes

REQUIRED INFORMATION

Consent

Paragraph

Name as shown on account

Taxpayer ID Number (SS# or EIN)

Mailing Address

City

State/Province

Zip/Postal

Taxpayer Consent

I hereby consent to include in my gross income, as now or hereafter provided in the federal income tax laws, the stated dollar amount of each written notice of allocation which I receive from Clallam Cooperative, P.O. Box 608, Sequim, WA 98382, with respect to my patronage occurring during the current and all subsequent taxable years of this cooperative. This consent shall be revocable by me at any time if in writing.

Certification – Under penalties of perjury, I certify that (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and (2) I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding.

Certification Instructions – You must cross out items (2) above if you have been notified by the IRS that you are currently subject to backup withholding because of under reporting interest or dividends on your tax return. However, if after being notified by the IRS that you were subject to backup withholding you received another notification from the IRS that you are no longer subject to backup withholding do not cross out item (2) The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid backup withholding.

Signature

Clear

Date

Patronage Dividends

Credit Application Member - Business

Credit Application - Business

Credit Limit

$500

Other

Credit Limit Requested Amount

Business Account Name

EIN#

Owner Name(s)

Years Established

Owners SS#

Birthdate

Drivers License #

Mailing Address

City

State/Province

Zip/Postal

Phone

Street Address

City

State/Province

Zip/Postal

Credit References

Name

City/State

Phone

Account Number

Balance

Name

City/State

Phone

Account Number

Balance

The following individuals are authorized to make charges to my account: (Please notify us immediately of any changes)

Do you want to receive your invoices via email?

Yes

Do you want to receive your statement via email?

Yes

Please provide your email:

Our Privacy Statement:

 Clallam Co-op respects your privacy. We do not sell, rent or give identifiable personal information regarding our customers to third parties. Information that you give us is held with the utmost care and security.

Our Terms

Our terms are “all sales are due and payable on or before the 10th of the month following date of purchase”. It further establishes a “finance charge” on all non-deferred balances more than 30 days old. The finance charge will be computed by a periodic rate of 1% per month or a .50 cent minimum. This is an “annual percentage rate” of 12% applied to all amounts and balances shown on your statement as being more than 30 days old. The closing date of each statement period (known as the billing cycle) will be shown on each statement. To avoid finance charges the “new charges” on each statement must be paid before the statement date for the next month. Our credit policy states those not meeting these terms will have their account placed on cash delivery (C.O.D.) until current. Any accounts with an outstanding balance exceeding 30 days will automatically become C.O.D. accounts, forfeit all member discounts, and remain such until the account is current. Collection proceedings may begin when an account exceeds 60 days.
I agree to pay the Co-op’s reasonable attorney’s fees in the event of non-payment and filing of suit to collect any balance I owe. Venue for suit shall be Clallam County, Washington, and I expressly waive all jurisdiction requirements of chapter 3.20 of the revised code of Washington as now or hereafter amended.
If you have questions, or desire further information, we will be pleased to have you come in and discuss them with us.

Acknowledgment

I acknowledge receipt and understand the “Notice to Customers” and agree to the payment terms and conditions. I submit the above facts as a basis for credit and warranty them to be true and accurate. I also certify that I am 18 years of age or older.

Signature

Clear

Date

Do you want to participate in the patronage payback?

Yes

REQUIRED INFORMATION

Consent

Paragraph

Name as shown on account

Taxpayer ID Number (SS# or EIN)

Mailing Address

City

State/Province

Zip/Postal

Taxpayer Consent

I hereby consent to include in my gross income, as now or hereafter provided in the federal income tax laws, the stated dollar amount of each written notice of allocation which I receive from Clallam Cooperative, P.O. Box 608, Sequim, WA 98382, with respect to my patronage occurring during the current and all subsequent taxable years of this cooperative. This consent shall be revocable by me at any time if in writing.

Certification – Under penalties of perjury, I certify that (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and (2) I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding.

Certification Instructions – You must cross out items (2) above if you have been notified by the IRS that you are currently subject to backup withholding because of under reporting interest or dividends on your tax return. However, if after being notified by the IRS that you were subject to backup withholding you received another notification from the IRS that you are no longer subject to backup withholding do not cross out item (2) The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid backup withholding.

Signature

Clear

Date

Patronage Dividends

Patronage dividends allow us to strengthen our co-op so we can continue to serve our community now and in the future. Every year that the Co-op is profitable, our board will have the option of allocating dividends to owners with some being retained as needed and some being distributed as deemed necessary.

Frequently Asked Questions

What is a Patronage Dividend?
When Co-ops have a surplus (a.k.a. profit) left over at the end of the fiscal year, the Board may vote to declare a share of the surplus to the members as distributable surplus. The surplus is allocated in direct proportion to a co-op member’s purchases in that fiscal year and that allocation is called a “Patronage Dividend.”

Why does the Co-op retain a percentage of the Patronage Dividend?
The Board of Directors will determine the percentage of the Patronage Dividend that is to be retained. This is done on a yearly basis. This amount will be used by the Co-op to operate, to grow, and to achieve our Ends.

What will influence the potential amount of my Patronage Dividend in future years?
Your dividend is related to how much you shop at the Co-op, how successful we are as a business, and the expenses we face in a given year. The more successful we are, and the more you contribute to that success, the more you could get refunded.

How are my purchases recorded?
In order to record your purchase, the cashier asks for your Owner number before each transaction. All merchandise rung through under your number is recorded by our system.

Do I have to pay income taxes on my patronage dividend refund?
Patronage dividend refunds are not taxable income unless your purchases were for purposes other than personal use. If this is the case for you, please consult your tax advisor.

Download membership form(s) here. (pdf format)