ULSTER COUNTY FARM BUREAU MEMBERSHIP APPLICATION

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Name
Title or Occupation
Organization or Farm Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work or Farm Phone
Home Phone
Fax
E-mail
Web Page URL


Please tell us a little about your farm or organization. In the spaces provided below, please list the major commodities produced by your farm, your farm interests or list the type of business.

Commodity or Business Emphasis

If you want to charge your membership to a credit card, please provide the
following information:

Ulster County Membership Dues are $65
$20 for Junior Membership

BILLING:

Credit Card
Cardholder Name
(As it Appears on your card)
Card Number
Expiration Date

Choose one of the following options: (Upon membership application acceptance, the appropriate County Farm Bureau determines the membership category of new and renewing members.)

If applying for Junior membership, please enter birth date in the space provided below.

Signature:________________________________________Date:_______________

Once you have completed this form, use your computer's print option to print this page. Then sign and date. Include a check for $65, for the Ulster County Dues. ($20 for Junior Membership) or complete the credit card information section of this form, then send to:

Ulster County Farm Bureau
C/O Deborah Weaver
897 Lapla Rd
Kingston NY 12401
845.338.3130

©2005 Ulster County Farm Bureau