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Florida Farm Bureau Membership Application
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County
Select a option
ALACHUA
BAKER
BAY
BRADFORD
BREVARD
BROWARD
CALHOUN / GULF
CLAY
COLLIER
COLUMBIA
DADE
DESOTO / CHARLOTTE
DUVAL
ESCAMBIA
FLAGLER
GADSDEN
GILCHRIST
HAMILTON
HARDEE
HENDRY / GLADES
HERNANDO / CITRUS
HIGHLANDS
HILLSBOROUGH
HOLMES
INDIAN RIVER
JACKSON
JEFFERSON
LAFAYETTE
LAKE
LEE
LEON
LEVY
LIBERTY
MADISON
MANATEE
MARION
MARTIN
NASSAU
OKALOOSA
OKEECHOBEE
ORANGE
OSCEOLA
PALM BEACH
WESTERN PALM BEACH
PASCO
PINELLAS
POLK
PUTNAM / ST JOHNS
ST LUCIE
SANTA ROSA
SARASOTA
SEMINOLE
SUMTER
SUWANNEE
TAYLOR
UNION
VOLUSIA
WAKULLA
WALTON
WASHINGTON
Choose the statement that best describes you
Select a option
I'm an individual
I'm representing a Business
Farmer Status
Select a option
I'm a fulltime farmer
I am a part-time farmer
I am an employee of a farm
I am neither a farmer nor an employee of a farm
Farmer Status Company
Select a option
I'm a fulltime farmer
I am a part-time farmer
I am an employee of a farm
I am neither a farmer nor an employee of a farm
Are you a 501(c)3 organization or a Non-Profit Organization
Select a option
Yes
No
Civil Status
Select a option
I'm married
I'm married with children (under the age of 21)
I'm single
I'm single with children (under the age of 21)
internalid
internalid Company
County Company
Select a option
ALACHUA
BAKER
BAY
BRADFORD
BREVARD
BROWARD
CALHOUN / GULF
CLAY
COLLIER
COLUMBIA
DADE
DESOTO / CHARLOTTE
DUVAL
ESCAMBIA
FLAGLER
GADSDEN
GILCHRIST
HAMILTON
HARDEE
HENDRY / GLADES
HERNANDO / CITRUS
HIGHLANDS
HILLSBOROUGH
HOLMES
INDIAN RIVER
JACKSON
JEFFERSON
LAFAYETTE
LAKE
LEE
LEON
LEVY
LIBERTY
MADISON
MANATEE
MARION
MARTIN
NASSAU
OKALOOSA
OKEECHOBEE
ORANGE
OSCEOLA
PALM BEACH
WESTERN PALM BEACH
PASCO
PINELLAS
POLK
PUTNAM / ST JOHNS
ST LUCIE
SANTA ROSA
SARASOTA
SEMINOLE
SUMTER
SUWANNEE
TAYLOR
UNION
VOLUSIA
WAKULLA
WALTON
WASHINGTON
Role
Select a option
Primary
Secondary
Other
Contact Details
Email
First Name
Last Name
Phone Number
Birthday
Gender
Select a option
Male
Female
Mailing Address
City
State
Zip Code
Country
Business Name
Phone Number Business
Billing Street
Billing City
Billing Country
Billing State
Billing Zip Code
Do you want to add a Billing Address different to Mailing Address?
Select a option
Yes
No
Other Street
Other City
Other State
Other Postal Code
Other Country
Spouse Contact Details
Spouse Email
Spouse First Name
Spouse Last Name
Spouse Phone
Spouse Birthday
Spouse Gender
Select a option
Male
Female
Child Contact Details
Child Email
Child First Name
Child Last Name
Child Phone (or Parents)
Child Birthday
Child Gender
Select a option
Female
Male
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