AMERICAN GRASSFED ASSOCIATION PO Box 461090Denver, CO 80246Phone/Fax: 877-77GRASSEmail: email@example.comWeb: www.americangrassfed.org CERTIFICATION RENEWAL 2019 Please complete the information in the section regarding number of animals harvested or milked. You will be able to pay with your credit cart immediately after submitting this form. Brands and Corporate companies paying yearly dues need to contact Carrie Balkcom - firstname.lastname@example.orgMember Number*Member number can be found on your certificatePay by*Check By MailVenmoCredit CardPlease enter last 4 Digit of Credit Card Number*Producer Company Name*Producer Name*Phone Number*Email* AddressCityStateZipIf you do not show any animals harvested or milked, please send a signed letter with the explanation. You must keep all fees current. Thank you - American Grassfed StaffNumber of Animals Harvested or Milked# of Beef Harvested @ $1.00Beef Total# of Bison Harvested @ $1.00Bison Total# of Dairy Harvested @ $1.00Dairy Total# of Sheep Harvested @ $0.25Sheep Total# of Goat Harvested @ $0.25Goat Total# of Dairy Milked @ $1.00Milked Total# of Pork Harvested @ $0.50Pork TotalTOTALSUBTOTAL Description Amount Total Certified Producer Membership $100.00 $100.00 Licensing for 2019 $100.00 $100.00 SUBTOTAL $200.00 PLEASE REMIT BY 1/15/2019 Processing Fee*processing fee of 2.9% + $ 0.30 Certified Producer Membership Price: $100.00 Licensing for 2019 Price: $100.00 Harvest/Milk Fees Price: $0.00 Credit Card Processing Fees Price: $0.00 PAYMENT BY CHECK TOTAL:PAYMENT BY VENMO TOTAL:PAYMENT BY CREDIT CARD TOTAL:(Includes credit card processing fee of 2.9% + $ 0.30 )American Grassfed Association is a 501.c.6 trade organization Total $0.00 Payment Card Number Expiry (MM/YY) Card Code Card Postal Code This iframe contains the logic required to handle Ajax powered Gravity Forms.