Name:____________________________________________________

Home Address:____________________________________________

City:____________________State:______ Zip:___________________

Business Address:_________________________________________

City:____________________ State:_____ Zip:____________________

Home Telephone Number:____________________________________

Business Telephone Number:_________________________________

Fax Number:______________________________________________

E-Mail Address:____________________________________________

(Please check one)

I would like to join as:

____Individual            ____Corporation       ____Partnership

Only individual members receive the accidental Death and Dismemberment

Policy as a part of their membership.

 

(Please check one)

I would like to receive my mail at the:

____Home Address        ____Business Address

 

To determine your level of membership, please select yes or no in response

to the following statement:

 

I now receive income or expect to receive income within the next year from

actual farming and ranching activities:

____Yes        ____No

 

Please check the preferences for us to contact you:

____Email        ____Telephone        ____Mail