MEMBERSHIP FORM - Federated Farmers

MEMBERSHIP FORM
MEMBERSHIP NAME
SUBSCRIPTIONS PRICE INCL GST
SERVICE PACKAGE 1 - Please tick (includes 0800 legal and employment advice
and discounted contracts and agreements)
TOTAL AMOUNT PAYABLE INCL GST $
NOTE:
Each membership is entitled to TWO named people apart from Farm Employee and Supporter who are entitled to ONE named person only
**Farm Managers and Farm Employees may be linked to the Business Owner/ Director category or be independent.
If linked enter your details (invoice will be sent to Business Owner)
BUSINESS TRADING / ENTITY NAME COMPANY EMAIL
NOMINATED PEOPLE (NOTE: Each membership [excluding Farm Employee/ Supporter rate] is entitled to TWO named people)
MEMBER ONE NAME FIRST NAME SURNAME EMAIL ADDRESS DOB
MEMBER TWO NAME FIRST NAME SURNAME EMAIL ADDRESS DOB
CONTACT DETAILS
ADDRESS
RAPID NUMBER ROAD NAME RURAL DELIVERY NUMBER
LOCALITY TOWN / CITY POST CODE
PHONE NUMBER MOBILE FAX
Business Owner/ Director
Farm Manager**
Rural Contractors
Farmlet
$598.00
$418.60
$418.60
$418.60
SERVICE PACKAGE 2 - Please tick or insert number required
Rural Services
Farm Employee**
Supporter
MEMBER NUMBER YOUR NAME AUTHORISED SIGNATURE
PAYMENT OPTIONS (Please tick chosen method of payment) Please note that a tax receipt will be sent to you upon receipt of payment together with your membership cards.
$264.50
$119.60
$119.60
ONLINE PAYMENT VIA www.fedfarm.org.nz CHEQUE INTERNET BANKING DIRECT DEBIT INVOICE
(We will send you an authority form)
Payee Name: Federated Farmers of NZ Inc, Payee’s Account NO. 03 0306 0626460 00
DAIRY ORDER SUPPLY NAME FARM NO. PARTY NO.
VISA MASTERCARD AMERICAN EXPRESS CRT FARMLANDS
Cardholder’s Name Expiry Date /
Cardholder’s Signature
Credit/CRT Card Number
Farmlands Shareholder Number
TICK DAIRY COMPANY Fonterra Tatua
Payment of a subscription, in the absence of written notice to the contrary, is deemed as an authorisation by the member to the Federation to disclose such information held by the Federation about that member, including postal and
electronic addresses, to such third parties for such purposes as the Federation considers compatible with the members’ interests. Under the rules of the Federation, membership is subject to approval by the Chief Executive
I/We hereby apply for membership and agree to be bound by the rules of Federated Farmers of New Zealand Incorporated as registered with the Registrar of Incorporated Societies.
SIGNATURE _________________________________________________________________________________________________ DATE _________________________________________
DATE

PLEASE TICK THE PROVINCE YOU WISH TO JOIN (Only tick one)
Northland Auckland Hauraki-Coromandel Waikato Bay of Plenty
Rotorua/Taupo Ruapehu Gisborne/Waiora Hawke’s Bay Tararua
Taranaki Wanganui Manawatu/Rangitikei Wairarapa Nelson
Golden Bay Marlborough West Coast North Canterbury Mid-Canterbury
South Canterbury North Otago Otago Southland
Branch (if known) ___________________________
PLEASE TICK YOUR MAIN INDUSTRY GROUP (Only tick one)
Dairy Meat & Fibre Grain & Seed High Country Goats/Mohair Rural Butchers Bees
OTHER INDUSTRY INTERESTS (You may tick more than one option)
Dairy Meat & Fibre Grain & Seed High Country Goats/Mohair Rural Butchers Bees
Poultry Deer Pigs Forestry Horticulture
PLEASE NAME YOUR COUNCILS
Regional ______________________________________________ District ______________________________________________
FOR STATISTICAL PURPOSES, CAN YOU PLEASE COMPLETE THE FOLLOWING
Business Owner/ Director
No of farms owned ____________________
I/We contract sharemilkers:
No. of sharemilkers ___________________
I/We Employ staff:
No of staff ___________________________
RETURN TO:
Federated Farmers of New Zealand
PO Box 447
HAMILTON 3240
OFFICE USE ONLY
Farm Size
Land size (ha) _______________________
No. of cows _______________________
No. of cattle _______________________
No. of sheep _______________________
Crop type _______________________
Other _______________________
(please specify)
Business Type:
Farm Owner
Farm manager
Farm employee
50/50 sharemilker
Variable Order Sharemilker
Contract Milker
Supporter
Retired
Employee
Casual Goat (Mohair)
Casual Bees
Bee Keeper
Less than 200 Greater than 200
Other _______________________________
Rural Professional
____________________________________
(please specify type of business)
Rural Contractor
____________________________________
(please specify type of business)
Field Officer (if applicable) ________________________________________________ Date ____________________________________________ Membership No.: __________________________
www.fedfarm.org.nz I 0800 327 646