EcoMart Northern Rivers Co-op Ltd

EcoMart Northern Rivers Co-op Ltd Membership Application

To become a member complete the following information and click submit.

+ Indicates a required field. ~ Indicates an optional field.

Section 1: General Information

+ First Name:		+ Last Name:
~ First Name 2:		~ Last Name 2:

~ Business Name:

Section 2: Contact Information

~ Work Address:
~ Work Address 2:
~ Town/State/Postcode:

+ Home Phone:		~ Work Phone:
~ And/Or ~
+ Mobile Phone:		~ FAX:
~ Toll Free:

+ Email Address:
~ Email Address 2:
~ Home Page:	http://

Section 3: Access Credentials

+ Username:	+ Enter the word	Human validation text
+ Password:
+ Confirm:

Section 4: Activity Type

+ Activity Type:

CONSUMER: Products purchased for your own use. A once only entrance fee of $10.00 and an annual subscription fee of $20.00 or 4 instalments of $5.00 paid with each order.
URBAN PRODUCER: Production area for fresh produce less than 1,000 sq m, or sale of processed goods not a substantial part of your income. A once only entrance fee of $10.00 and an annual subscription fee of $20.00 or 4 instalments of $5.00 paid with each order.
COMMERCIAL PRODUCER: Production of fresh produce or processed goods is a substantial part of your income. A once only entrance fee of $10.00 and an annual subscription fee of $20.00.
INSTITUTIONAL BUYER: Products purchased for resale or processing. A once only entrance fee of $10.00 and an annual subscription fee of $20.00.

Section 5: Additional Information

Indicate your preferred pick-up/drop-off location. Ballina, Byron Bay, Casino, Mclean, Kyogle, Lismore, Murwillumbah.

+ Pick-up/Drop-off Location:
~ How you heard about EcoMart Northern Rivers Co-op Ltd:
~ Please give more detail:	What website, from whom, which publication/date, etc.?

~ YES! I‘m interested in volunteering to help EcoMart Northern Rivers Co-op Ltd.

~ I am interested in becoming a producer member for EcoMart Northern Rivers Co-op Ltd.

+ I acknowledge that I have familiarised myself with the Co-op Rules and supporting documents and understand the
EcoMart Northern Rivers Co-op Ltd Terms of Service statement.

+ Address:

~ Address 2:

+ Town/State/Postcode:

~ Do Not Send Postal Mail: