Attached is my remittance of $______________

For the fiscal year of January 1, _____ to December 31, ______

NAME: ________________________________________________________________

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Farm Name: ____________________________________________________________

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I wish to be listed in the catalog and website by Name_______ or Farm Name_________

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Address: _______________________________________________________________

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City: _________________________________ State: __________  Zip: _____________

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E-mail: ________________________________________________________________

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Web site: ______________________________________________________________

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Phone Number: ___________________________ Cell Phone: ____________________

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