Step 1 of 4 25% * Required General Member InformationThe membership information you provide to us is strictly confidential. We do not loan or sell your information to any groups or businesses. I have previously had a CFBA membership I am renewing my membershipYesNoMembership Number*First Name*Middle InitialLast Name*Birthdate Farm Name or BusinessMailing Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip Code County*This is the county you want to be a member in, NOT necessarily your residential county. - Select -FairfieldLitchfieldNew HavenTollandHartfordMiddlesexNew LondonWindhamOut of StateSpouse's Name First Last Spouse's Birthdate Contact InformationSelect all phone types that apply. At least one phone is required* Home Phone Farm or Work Phone Cell Phone Home PhoneFarm or Work PhoneCell PhoneEmail* An email address is required to join online. If you do not have an email address, please call 860-768-110 Monday through Friday between 8:30AM and 4:30PM and we will help you join over the phone. Farm or Business Website I am...Please select your membership level below.*FULL-TIME FARMER - $200PART-TIME FARMER - $100FRIEND OF AGRICULTURE - $70STUDENT MEMBER - $30CONNECTICUT VEGETABLE & BERRY GROWER'S ALLIANCE(PART-TIME) - $100CONNECTICUT VEGETABLE & BERRY GROWER'S ALLIANCE(FULL-TIME) - $200Farm InformationSize of Farm Operation- Select -Small: 1-9 AcresMid-Size: 10-49 AcresLarge: 50+ AcresCommodities Produced - Choose all that apply Dairy Fruit Grains Hay Horses Livestock Poultry Vegetables Forest-Products Aquaculture Nursery Maple-Syrup Honey Christmas-Trees Other Volunteer InformationI would be interested in volunteering with the following: County Activities Legislative Activities Policy Development Women's Committee Young Farmers Committee (Age 18-35) Nationwide InsuranceNationwide insurance provides a wide array of agricultural related insurance coverage. Would you be interested in a free insurance quote? Yes, I am interested in a free quote on agricultural related insurance coverage. Are you an Nationwide insurance agent, or are you working with a Nationwide insurance agent?*YesNoAgent InformationPlease enter your insurance agent's information here.Agent NameAgent NumberAgent Email Agent Phone Number Auto Renewal Save $5.00 when you sign up for Automatic Renewal Worry-free renewal every year Your credit card or bank account information will be stored securely by a third party service You’ll be notified each year before payment is made Help save CFBA the cost of printing and mailing membership invoices There is no penalty or fee to end the automatic deduction – simply call or email CFBA and we will end the withdrawals Would you like to sign up for Auto-Renewal?*Yes! I'd like to save $5.00. Sign me up for automatic renewalNo. I do not want to sign up for automatic renewal Payment InformationPLEASE NOTE MEMBERSHIP DUES ARE NOT REFUNDABLEFull Time Member 200 Price: $200.00 Full Time Member Auto 195 Price: $195.00 Part Time member 100 Price: $100.00 Part Time member Auto 95 Price: $95.00 Friend of Agriculture member 70 Price: $70.00 Friend of Agriculture member Auto 65 Price: $65.00 Full-Time CT Vegetables & Fruit Grower's Alliance member 200 Price: $200.00 Full-Time CT Vegetables & Fruit Growers Alliance member Auto 195 Price: $195.00 Part-Time CT Vegetables & Fruit Grower's Alliance member 100 Price: $100.00 Part-Time CT Vegetable & Fruit Grower's Alliance member Auto 95 Price: $95.00 Student member 30 Price: $30.00 Your annual membership is only: $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Security Code Cardholder Name Billing Address InformationPayer Name First Last Payer PhoneBilling Address* llllllBilling address same as member address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip Code This iframe contains the logic required to handle Ajax powered Gravity Forms.
