NATIONAL ASSOCIATION OF FARMER ELECTED COMMITTEE

Membership Application/Renewal Form

NAME: _________________________________________________________

ADDRESS: ______________________________________________________

CITY/STATE/ZIP: _________________________________________________

PHONE NUMBER: ________________________________________________

FAX NUMBER: ___________________________________________________

CELL PHONE: ____________________________________________________

E-MAIL: _________________________________________________________

Would you prefer to have the newsletter sent to electronically? Yes ____ No ____

Are you submitting an FSA-444 to your County FSA office for automatic dues

withholding? Yes ____ No ____

If yes, please remember to send your personal information to NAFEC or have your FSA

office do so.

__________ Committee members - $35

__________ FSA employee or Associate member - $20

If paying by check, please make payable to NAFEC.

Mail to: Paul Clark

NAFEC Secretary-Treasurer

751 Knox Highway 12

Gilson, IL 61436

http://nafec.org