New member information (gift recipient)

First Name *

Last Name *

Farm/Business name (if applicable)

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number

Phone type

Email Address

Current member information (gift giver)

First Name *

Last Name *

Farm/Business name (if applicable)

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Phone type *

Email Address *

Membership Details

Length of membership to gift: *

1-yr membership to ICGA ($75)

3-yr membership to ICGA ($145)

Lifetime membership ICGA ($1000)

Membership type: *

Regular (producer) membership: For individuals who are farmer-owners or operators

Associate membership: For individuals or firms whose business concerns corn growers

Memberships are automatically invoiced one month prior to membership lapse date. Knowing this, what billing address should IL Corn use for future membership invoicing? *

Gift recipient's address

Gift giver's address

N/A (for lifetime members only)

Delivery Details

Gift message to recipient:

Delivery Method Notes: New/Renewed member packets are mailed at the end of each month. New member packet will include gift certificate, membership card & ICGA Annual Report *

Deliver to me, the gift giver.

Ship directly to recipient.

RUSH delivery required

by this date: by this date:

Payment information

Name on Card

Credit Card Type

Credit Card Number

Expiration Date (mm/yy)

3-digit CVV code

Alternate form of payment:

I will mail a check (ICGA PO Box 1623, Bloomington, IL 61702-1623)

I will pay with credit card over the phone (ICGA Office # 309-557-3257)