Permaculture Growers Co-op: Small Farms Feeding Bloomington

Account Information

1. What is Your First Name?
   First Name:
2. What is Your Last Name?
   Last Name:
3. What is Your Email Address?

   You need an email address to use our system.

   Email Address:
4. What is Your Phone Number?

   Please enter a number where we can reach you on pick-up days. If it gets close to time to pack up and you haven't picked up your order (everyone forgets at least once!), we'll give you a call at this number.

   Phone Number:
5. What is Your Mailing Address?

   We may not use this for anything, but if we ever print up newsletters, postcards, or anything like that, it'd be nice to know how to send you one.

   Address (Line One):
   Address (Line Two):
   City:
   State/Province:
   ZIP/Postal Code:
6. Create an Account Name

   You'll use this name to log into your account.

   Account Name:
7. Assign Yourself a Password

   It must be at least five characters long.

   Password:
8. Finally, Confirm Your Password

   It must match what you just typed above.

   Password (Again):