Membership_old

I am...
Please select your membership type below.*
- Regular/Farmer
- Regular/Retired
- Forester
- Associate/Non Farmer
- Business/Organization
- Other States Member
- VTFB Employee
Are you an insurance agent, or are you working with an insurance agent?*
- Yes
- No
Insurance Information
Get ready to save! Please enter your insurance agent's information here.
Agent*
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Agent ID*
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Agent Name*
Agent Number*
Agent Email
Agent Phone Number

Contact Info
Membership Number
*
First Name Middle Name Last Name
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Birthdate
YYYY dash MM dash DD
Spouse's First Name
Spouse's Last Name
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Spouse's Birthdate
MM slash DD slash YYYY
Email Address (This field is required to make an online payment)*
County*
Home Phone
Work Phone
Cell Phone
Address*
Street Address Address Line 2 City State Zip Code
Township(s) you are located in
Farm Info
Farm Name
Size of Farm Operation

Commodities Produced

I am...