Attached is my remittance of $______________

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

NAME: ________________________________________________________________

Farm Name: ____________________________________________________________

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

Address: _______________________________________________________________

City: _________________________________ State: __________  Zip: _____________

E-mail: ________________________________________________________________

Web site: ______________________________________________________________

Phone Number: ___________________________ Cell Phone: ____________________