Minnesota Corn Partial Refund Membership Form

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Membership Information

Complete the form below to become a member of the Minnesota Corn Growers Association using check-off dollars. The person responsible for the sale of the corn will need to sign at the bottom.

First & Last Name

Farm/Company Name

Spouse

Address(Required)

Street Address Address Line 2 City State ZIP Code

Membership County(Required)

Email(Required)

Home Phone

Business Phone

Cell Phone

Please add at least one type of phone number.

Cell Phone Text Messages

Opt-Out

I understand that by providing my information above, I consent to receive communications by or on behalf of the MCGA organization via mail, email, telephone or text.

Member Option(Required)

1 Year Membership = 7,500 bu. of corn sold and checked-off in Minnesota within the past 12 months ($75 value)

3 Year Membership = 20,000 bu. of corn sold and checked-off in Minnesota within the past 12 months ($200 value)

Young Adult Membership = 2,000 bu. of corn sold and checked-off in Minnesota within the past 12 months ($20 value)

Birth Month/Year(Required)

Young adults must be between the ages of 16-24. Please provide birth month & year.

Member Type(Required)

Individual

Farm/Company

Current Member Status(Required)

New

Renewal

Member ID # (if known)

Recruiter Name

Verification

By signing this form, I certify that I have sold, checked-off and not previously refunded in Minnesota the above checked number of bushels of corn within 12 months of this date. I authorize and assign payment for a membership in the Minnesota Corn Growers Association (MCGA). This partial refund is to be paid from the first dollars collected on my corn checkoff assignment.

Signature(Required)

Signature must be of individual responsible for the sale of corn.

Print Name

Date(Required)

Phone(Required)

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