How to Join - Southern Mountain Fresh

Information Regarding Prospective Member
Name:
Address:
Business Phone #:
Home Phone #:
Mobile Phone #:
Fax #:
Email 1:
Email 2:
Prospective Member is an:
	Individual Entity

If the Prospective Member is an entity, please list the name of the Prospective Member's primary representative:


Qualifications for Membership (check all that apply):
	The Prospective Member is involved in agriculture or agribusiness in Henderson County (please describe involvement):

	The Prospective Member provides goods or services to agribusinesses in Henderson County (please describe goods or services provided):

	The Prospective Member has a significant interest in promoting agriculture or agribusiness in Henderson County (please describe such interest):


Membership is subject to approval by Agribusiness Henderson County, Inc. and shall be contingent upon the Prospective Member's execution of a Membership Agreement.
Today's Date:
Name of Prospective Member:
Title (if Prospective Member is entity):

Membership Level (check one)