Click here to print the Membership Application and Milk Check Assignment form

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Membership Application and Milk Check Assignment

Dairy Pricing Association, Inc.

The patron listed below requests the following checkoffs to be deducted from their monthly milk check and forward to to Dairy Pricing Association Inc. (DPA). The patron may choose any combination of checkoffs per cwt: 15 cents, 10 cents, 5 cents, and 2 cents.

Patron Name                                                                               Patron Number

Address

City                                                                 State                      Zip

Phone                                                              Email Address

Patron Signature                                            Date                      If organic, check here:

Dairy Plant/Marketer Name:

Address:

City                                                                 State                    Zip

Phone

IF THIS IS A CHANGE TO EXISTING CHECK OFF, MARK THIS LINE: ______

The patron selects the following checkoff(s):

2 Cents per cwt _____
5 Cents per cwt _____
10 Cents per cwt _____
15 Cents per cwt _____

NOTE: You may choose for 10 cents per cwt of the 15 cent assignment to go toward the purchasing of whole milk powder. Please check here: ____ YES or ____ NO

According to Dairy Pricing Association (DPA) bylaws your 10 cents per cwt is required to be a voting member. The producer can terminate this check off at any time.

Note: If there is a humanitarian relief organization in your area that you would like Dairy Pricing Association, Inc. to donate to, please give us contact information.

Application may be mailed or faxed to:

Dairy Pricing Association, Inc.
W15311 Franklin Road
Taylor, WI  54659

Phone: (715) 284-2590
Fax: (715) 284-2591

The DPA is a 501C5, which is a not for profit organization. Your accountant/tax preparer can advise you as to the tax status of your donation.