Membership Application Individual Hensall Co-op

Membership Application - Individuals

If you have any questions please call 1.800.265.5190, option 2.

Disclaimer: By completing this application you authorize and consent that Hensall District Co-Operative, Incorporated can release your information when required by the Co-Operative Corporations Act (section 120).

If you prefer - we have a pdf form that can be completed and returned to us:

Individual Membership Application Direct Deposit Form

* Applicant's Full Legal Name:
* Full Mailing Address (include 911 municipal address, Town/City, Province and Postal Code)
* Primary Phone The number you can be contacted at during regular business hours.
Mobile Phone (if different from Primary)
**Date of Birth (DD/MMM/YYYY)
Social Insurance Number (SIN) If you would rather not provide your SIN and DOB via this online form, please complete the rest of the form and submit it, then call 519-262-3511 ext 357 with your details.
* Email Address
Co-Applicant (if applicable)
Type of Account	Or (Meaning only one party must sign or authorize deposits and withdrawals) And (Meaning all parties must sign or authorize deposits and withdrawals)
Co-applicant's Full Legal Name:
Co-applicant's full mailing address (include 911 municipal address, Town/City, Province and Postal Code)
Co-Applicant's Phone:
Cell Number:
Date of Birth (DD/MMM/YYYY)
Co-applicants Social Insurance Number (SIN) **If you would rather not provide your SIN and DOB via this online form, please complete the rest of the form and submit it, then call 519-262-3511 ext 357 with your details.
Co-applicant's Email Address
Additional Information
Farm Type	Cash Crops Livestock (Swine) Livestock (Poultry) Livestock (Dairy) IP/Dry Beans Other N/A
Products & Services Requested	Grain Marketing Energy (Fuel/Propane) Crop Input Products (Fertilizer, Seed, Ag Chemicals) Food Grade Soybeans Edible Dry Beans Animal Nutrition Investments
Size of operation - Acres owned:
Size of operation - Acres rented:
Do you have any on farm storage?	Yes No
If yes, how much on farm storage do you have?
Closest Hensall Co-op location
Do you currently do business with Hensall Co-op?	Yes No
If yes, who is your current Hensall Co-op Contact
What business divisions would you like to learn more about	Grain Marketing Energy (Fuel/Propane) IP/Dry Beans Crop Input Products (Fertilizer, Seed, Ag Chemicals) Animal Nutrition
How did you hear about Hensall Co-op	Social Media Friend/Family Ontario Farmer Other
* I agree to receive Hensall Co-op emails about Ag Alerts, Product Updates, Promotions and Member Newsletters	Yes No
* A void cheque AND direct deposit form must be submitted. I agree to forward a copy of these via one of the following: 1) email to memberservices@hdc.on.ca; 2) fax at 519-262-2317: 3) mail to Hensall Co-op at 1 Davidson Drive Hensall ON N0M 1X0; or 4) deliver to a Hensall Co-op location, Attention: Membership. The Direct Deposit form link is provided at the top of this page. Please complete, sign electronically, save and return to us. Agree
* Original piece of identification must be provided for each applicant. Send copies of 2 pieces of identification per applicant. (E.g. driver’s license, passport, permanent resident card, provincial government ID card, void cheque etc. Health cards are not an acceptable form of identification.) I agree to forward identification via one of the following: 1) email to memberservices@hdc.on.ca, 2) fax at 519-262-2317: 3) mail to Hensall Co-op at 1 Davidson Drive Hensall ON N0M 1X0; or 4) deliver to a Hensall Co-op location, Attention: Membership. Agree
* One-time membership fee of $100 How will you be paying?	Sending a cheque On-line bill payment through my bank Credit Card (2.40% Surcharge)
* Apply for membership By selecting ‘Agree’ and submitting this form, you are signing this application electronically, agree your electronic signature is the legal equivalent of your manual signature and agree to the terms and conditions stated. Agree