________________
Dues are NOT deductible as charitable contributions or as farm business expenses.
Control Number
FARM BUREAU & FARM BUREAU HEALTH PLANS
MEMBERSHIP AGREEMENT
______________________________
Voting District
Proposed Classification
New Change
Member Agricultural Member
Applicant Name(s) Please print
First
Middle
Last
Title
DOB
Marital Status
Gender
Business Name
Address
City
State
Zip
Country if other than USA
Email
Home Phone
Work Phone
Cell Phone
The undersigned hereby applies for a family membership in the ______________________________________________________________
County Farm Bureau (County), renewable annually, and through its affiliation with the Tennessee Farm Bureau Federation
(TFBF) and American Farm Bureau Federation (AFBF).
The applicant believes in the future of Tennessee agriculture and supports Tennessee farm families and production agriculture. The applicant
endorses the organization’s mission to "develop, foster, promote, and protect programs for the general welfare, including economic,
social, educational and political well-being of farm people of the great state of Tennessee", and will promote this mission by
educating and cooperating with the public and private sectors charged with enacting or administering laws and policies affecting agriculture.
The applicant acknowledges that membership dues of $30 each year are distributed as follows: County $10.75; TFBF $12.25; $1
split evenly among all Tennessee county Farm Bureaus; AFBF $5; publications $1. Dues not paid by the due date are subject to a $5
late fee. The applicant understands that these membership dues are subject to increase only by the house of delegates at the
TFBF Annual Meeting. This agreement also includes membership in Tennessee Rural Health Improvement Association, DBA -
Farm Bureau Health Plans.
The applicant hereby tenders payment of the initial $30 annual membership by cash, check, or automatic withdrawal
authorization.
Signature
Date Signed
Membership Transfer Authorization (If applicable)
As a convenience to me, if I move to another county in Tennessee, I request my membership be automatically transferred to that county
Farm Bureau subject to its approval process. I understand and acknowledge that any membership application provided to Farm Bureau Health
Plans will be sent to the Tennessee Farm Bureau.
click to sign
signature
click to edit
Tennessee Farm Bureau Federation
Authorization for Payment by EFT
Membership Name: Member #:
B
ank Name
: A
ccount Type:
R
outing #
: A
ccount #
:
Debit Entries: As a convenience to me, I hereby authorize Tennessee Farm Bureau Federation (TFBF) to initiate debit
entries to the account identified above for annual membership payments (the charge) on the membership set forth
above. I acknowledge that I am signing this agreement on behalf of all family members on the membership, and
signatories to the account and am authorized to do so.
Terms of Authorization: I understand and agree that this authority is to remain in full effect until TFBF and the bank
identified above (Bank) have received written notification from me of its termination in such time and in such manner
as to give TFBF and Bank a reasonable opportunity to act upon it. I agree that TFBF's treatment of such charge, and
TFBF's rights in respect to it, shall be the same as if it were signed personally by me. I further agree that if any
electronic funds transfer (EFT) for membership payment is not honored when presented to the bank on which it is
drawn, whether with or without cause and whether intentionally or inadvertently, a $5 late fee will be added to my
dues. If said charge is not remedied within thirty days from the assigned date of the charge, then my membership will
release. Additional fees may apply for charges not honored.
Date and Amount of Charge: I understand and agree that the charge shall be scheduled to occur on or about the same
day of each year based upon the membership period dates. Variances in the charge date may occur due to weekend and
holiday processing.
Cancellation and Lapse: I understand and agree that this payment plan and the membership to which it relates may be
cancelled by me at any time in accordance with membership provisions. Membership may also lapse for non-payment
or be cancelled by TFBF for any other reason in accordance with membership provisions.
Reinstatement: I understand and agree that if this membership lapses for non-payment, or if it is cancelled in
accordance with membership provisions, if and when the membership is reinstated the date of the charge will change to
the new due date set by TFBF.
Miscellaneous: I understand and agree that all changes in account information must be received by TFBF no later
than one (1) business days before payment is scheduled to be made. This agreement is subject to change or
cancellation by TFBF upon notification.
I hereby agree to the terms and conditions stated in this form on behalf of all members.
B
ankholder’s Signature
:
Date:
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome