Membership Form

CSA Membership Form Summer 2012

June 6, 2012 - September 26, 2012

Name: ________________________________________________________________________________________

Phone Number: _________________________________________________________________________________

Email: ________________________________________________________________________________________

Address: ______________________________________________________________________________________

City:______________________________________________State: ____________ Zip Code:_________________

Pick-up location (Wednesday afternoons)

◊ 3214 Thayer St Evanston, Il 60201

◊ 4827 N Paulina St Chicago, Il 60640

Size of share

◊ Full Share

Early Special- $500

After Feb 15, 2012 - $550

◊ Half share (full package delivered bi-weekly)

Early Special - $275

After Feb 15, 2012 - $300

Please print and mail with check made payable to Lake Breeze Organics to

3522 Pier Rd, Benton Harbor Mi, 49022