M-21 Membership Report by Order 30 Qualified Cooperative Asso

FEDERAL MILK MARKET ADMINISTRATOR

MEMBERSHIP REPORT BY ORDER 30 QUALIFIED COOPERATIVE ASSOCIATION

FORM APPROVED, OMB 0581-0032

UPPER MIDWEST MARKETING AREA
P.O. BOX 4469
LISLE, ILINOIS 60532-9469

(1) NOTICE OF ADDITION TO MEMBERSHIP
M-21

(2) NOTICE OF MEMBER TRANSFERRING BETWEEN PLANTS
Date
(NAME OF HANDLER TO WHOM MEMBER IS DELIVERING)

PATRON
NUMBER

(PLANT)

PATRON'S NAME (FIRST AND LAST)
ADDRESS & LOCATION OF FARM

STOCK
CERTIFICATE
OR
CONTRACT NO.

DATE OF
CONTRACT
OR
CERTIFICATE

EFFECTIVE
DATE OF
CHECK OFF

OLD MEMBER TRANSFERRING
TO ABOVE PLANT FROM
PLANT

PATRON NO.

(PLEASE PRINT)

NAME
ADDRESS
FARM LOC.
TWP.

COUNTY

STATE

TWP.

COUNTY

STATE

TWP.

COUNTY

STATE

TWP.

COUNTY

STATE

TWP.

COUNTY

STATE

NAME
ADDRESS
FARM LOC.
NAME
ADDRESS
FARM LOC.
NAME
ADDRESS
FARM LOC.
NAME
ADDRESS
FARM LOC.
The records of this association are available for your examination for the purpose of verifing the above data.

BY

TITLE
(PERSON AUTHORIZED TO SIGN FOR THE ASSOCIATION)

(NAME OF QUALIFIED COOPERATIVE ASSOCIATION)

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the data needed, and completing and reviewing the collection of information.
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