CONFIDENTIAL CONFIDENTIAL Today’s Date: _______________ Cooperative Name:_______________________________________________________ Fiscal Year End:_________________________ Mailing Address:______________________________________ City:__________________ State:_______ Zip:_____________________ Name:______________________________________________________ Position:_________________________________________________ Phone:______________________________________ Fax:________________________________ Email:______________________________ Cell Phone:______________________________ I would like to receive text message updates from OACC. __Yes __No Company Contacts to Receive Information from the OACC: If you would for someone other than yourself to receive information from the OACC on behalf of your company, please fill out the appropriate information below. Name: _______________________________________________________ Title:___________________________________________________ Mailing Address: ___________________________________ City: _____________________ State: ______ Zip: ___________ Phone: ______________________________________________ Email: __________________________________________________ Name: _______________________________________________________ Title:___________________________________________________ Mailing Address: ___________________________________ City: _____________________ State: ______ Zip: ___________ Phone: ______________________________________________ Email: __________________________________________________ Name: _______________________________________________________ Title:___________________________________________________ Mailing Address: ___________________________________ City: _____________________ State: ______ Zip: ___________ Phone: ______________________________________________ Email: __________________________________________________ Name: _______________________________________________________ Title:___________________________________________________ Mailing Address: ___________________________________ City: _____________________ State: ______ Zip: ___________ Phone: ______________________________________________ Email: __________________________________________________ Name: _______________________________________________________ Title:___________________________________________________ Mailing Address: ___________________________________ City: _____________________ State: ______ Zip: ___________ Phone: ______________________________________________ Email: __________________________________________________ Name: _______________________________________________________ Title:___________________________________________________ Mailing Address: ___________________________________ City: _____________________ State: ______ Zip: ___________ Phone: ______________________________________________ Email: __________________________________________________ Name: _______________________________________________________ Title:___________________________________________________ Mailing Address: ___________________________________ City: _____________________ State: ______ Zip: ___________ Phone: ______________________________________________ Email: __________________________________________________ Name: _______________________________________________________ Title:___________________________________________________ Mailing Address: ___________________________________ City: _____________________ State: ______ Zip: ___________ Phone: ______________________________________________ Email: __________________________________________________ Please return survey with dues check to: OACC, PO Box 13548, Oklahoma City, OK 73113 or use an online fillable form at www.okagcoop.org. And return by email to [email protected]. 1