Choose All That Apply *

I am moving to another community

I am shopping elsewhere now

The BCS stores are not convenient for me

Other

Choose One *

I would like to donate my equity to Bloomingfoods, where it will be used to continue improving operations to better serve the Bloomington community.

I would like a refund of my equity.

Name *

First Name

Last Name

Mailing Address *

Please provide address where you'll be receiving mail in 60 days.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date *

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