Membership Registration Form

Name*

First NameLast Name

IndividualBusiness/Corporation

DBA?

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birthdate *

Date

E-mail*

Phone Number:*

Area CodePhone Number

Phone # Type*

Type a question*

Farm Owner/Operator with $2,500 Gross Farm Income - MM MembershipFull-Time on Farm Employee - MM MembershipEmployed in Ag-Related Occupation - PM MembershipNone of the Above ("A" Associate)

Membership*

M Members (MM) $70.00Professional Members (PM) $70.00Associate (A) $20.00

Occupation

Thank you for filling out the application to become a Farm Bureau Member! Someone from our office will be in contact with you within the next business day to take payment for your membership.

Thank you!

Any Questions?

This application is subject to acceptance by the county Farm Bureau board and the Illinois Agricultural Association. I agree to pay
membership dues in the amount fixed in the bylaws of the county Farm Bureau and the Illinois Agricultural Association for each
succeeding membership year in advance so long as this agreement remains in effect. In the event this application is not accepted,
the membership dues paid will be refunded. The county Farm Bureau reserves the right to re-classify my membership in accordance
with the bylaws of the county Farm Bureau and the Illinois Agricultural Association. This agreement can be terminated by either
party by supplying written notice to the other party 60 days prior to the end of the membership year, but membership dues
are not refundable.