Login
Join
Get Involved
Membership
Leadership
Tomorrow’s Agribusiness Leaders
Sponsors
Kansas Agri Business Council (PAC)
CCA Program
Calendar
Online Directory
News
Seed to Silo
Newsroom
Events & Training
Advocacy
Resources
Get Involved
Membership
Leadership
Tomorrow’s Agribusiness Leaders
Sponsors
Kansas Agri Business Council (PAC)
CCA Program
Calendar
Online Directory
News
Seed to Silo
Newsroom
Events & Training
Advocacy
Resources
Application
To view this form, please enable JavaScript in your browser.
Organization Information (to be displayed online)
Organization Name
Address 1
Address 2
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
AG
BN
BS
CH
CL
CM
CP
DF
DU
GR
GT
JA
MC
MR
MX
NA
OA
PU
QE
QR
SI
SL
SO
TB
TL
TM
VE
YU
ZA
Outside US
Outside Canada
Outside Mexico
Zip
Phone
Fax
Website
Email
Main Contact
Copy from Organization-Information
First Name
Last Name
Address 1
Address 2
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
AG
BN
BS
CH
CL
CM
CP
DF
DU
GR
GT
JA
MC
MR
MX
NA
OA
PU
QE
QR
SI
SL
SO
TB
TL
TM
VE
YU
ZA
Outside US
Outside Canada
Outside Mexico
Zip
Title
Phone
Email
Additional Contacts
Contact 1
First Name
Last Name
Title
Email Address
Contact 2
First Name
Last Name
Title
Email Address
Contact 3
First Name
Last Name
Title
Email Address
Contact 4
First Name
Last Name
Title
Email Address
Contact 5
First Name
Last Name
Title
Email Address
Contact 6
First Name
Last Name
Title
Email Address
Contact 7
First Name
Last Name
Title
Email Address
Contact 8
First Name
Last Name
Title
Email Address
Contact 9
First Name
Last Name
Title
Email Address
Contact 10
First Name
Last Name
Title
Email Address
Add/Remove Contacts
Billing Address (if different)
Address 1
Address 2
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
AG
BN
BS
CH
CL
CM
CP
DF
DU
GR
GT
JA
MC
MR
MX
NA
OA
PU
QE
QR
SI
SL
SO
TB
TL
TM
VE
YU
ZA
Outside US
Outside Canada
Outside Mexico
Zip
Mailing Address (if different)
Address 1
Address 2
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
AG
BN
BS
CH
CL
CM
CP
DF
DU
GR
GT
JA
MC
MR
MX
NA
OA
PU
QE
QR
SI
SL
SO
TB
TL
TM
VE
YU
ZA
Outside US
Outside Canada
Outside Mexico
Zip
Additional Information
Referred By
How did you hear about us?
What is your reason for joining?
Please have someone contact me regarding
Association Involvement
Government Relations
Training Opportunities
Other
Membership Investment
Membership Type
Select one...
Retail
Associate
Basic Manufacturers (Up to 10 Representatives)
Wholesale/Distributors (Up to 3 Representatives)
Equipment Manufacturer (Up to 3 Representatives)
Equipment Distributor (Up to 2 Representatives)
Primary Directory Category
None
KARA Cancelled - Don't List
KARA Directory
KGFA Cancelled - Don't List
Member Directory
Additional Directory Categories
Select additional directory categories below by holding the "CTRL" key
Secondary categories may be subject to additional fees
none
Number of Full Time Employees
Number of Part Time Employees
Number of Additional Locations
Number of Extra Sales Reps (see membership type for number of reps included in your membership)
Annual Membership Investment
Total
The contents of this box are for testing purposes. This box will be removed when the form goes live.
Additional Items
Additional Categories Cost
One-Time Application Fee
Tax
Number of Rooms
Number of Seats
Number of Associates
Full-Time Employees
Part-Time Employees
Hotel/Motel Rooms
Restaurant Seats
Additional Associates
Additional Associates Cost
Additional Locations
Additional Locations Cost
Assets
Assets Cost
Additional Categories
Number Of Additional Categories
Additional Categories Cost
Additional Item 1 Cost
Additional Item 2 Cost
Additional Item 3 Cost
Additional Item 4 Cost
Additional Item 5 Cost
Additional Item 6 Cost
Additional Item 7 Cost
Additional Item 8 Cost
Additional Item 9 Cost
Additional Item 10 Cost
Annual Dues (charged to card)
Revenue Item
Tax (charged to card)
Fee (charged to card)
Temp Value For DropDown 1
Membership Type
Additional Item 1
Additional Item 2
Additional Item 3
Additional Item 4
Additional Item 5
Additional Item 6
Additional Item 7
Additional Item 8
Additional Item 9
Additional Item 10
Payment Type
Credit Card
Check
NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks.
Credit Card Information
Copy from Organization Information
Credit Card Type
Mastercard
Visa
Discover
Amex
Credit Card Number
Name on Card
Security Code
Valid Through
01
02
03
04
05
06
07
08
09
10
11
12
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
Address
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
AG
BN
BS
CH
CL
CM
CP
DF
DU
GR
GT
JA
MC
MR
MX
NA
OA
PU
QE
QR
SI
SL
SO
TB
TL
TM
VE
YU
ZA
Outside US
Outside Canada
Outside Mexico
Zip
Phone
Credit Card Email Address
Please click submit only one time. The transaction may take several seconds.
Please select a membership type before submitting your application.
X
X