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<title>Agribusiness Council Membership Form</title>
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<td width="100%"><p align="center"><font face="Arial" size="2"><strong><br>
<img border="0" src="images/agrilogo-small.gif" width="100" height="111"> </strong></font></p>
<p align="center"><font face="Arial" size="2"><strong>
<img border="0" src="images/argilogo2.gif" width="388" height="46"><br>
P.O. Box 5565<br>
Washington DC 20016</strong></font></p>
<p align="center"><font face="Arial" size="2"><strong>NOMINATION FORM<br>
<br>
</strong></font><b><font color="#FF0000" face="Arial" size="1">There is no
financial obligation in returning this form. <br>
You will receive additional information from the Nominating Committee.</font></b></p>
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<div align="center">
<center><table border="0" cellpadding="3" width="329">
<tr>
<td width="325" colspan="2" bgcolor="#A0CFCF">
<p align="center"><strong><font face="Arial" size="2">Name and
Address</font></strong></p>
</td>
</tr>
<tr>
<td width="125"><font face="Arial" size="2">Organization name: </font></td>
<td width="192"><font face="Arial" size="2"><input type="text" name="OrganizationName" size="20"></font></td>
</tr>
<tr>
<td width="125"><font face="Arial" size="2">Address:</font></td>
<td width="192"><font face="Arial" size="2"><input type="text" name="Address" size="20"></font></td>
</tr>
<tr>
<td width="125"><font face="Arial" size="2">City:</font></td>
<td width="192"><font face="Arial" size="2"><input type="text" name="City" size="20"></font></td>
</tr>
<tr>
<td width="125"><font face="Arial" size="2">State:</font></td>
<td width="192"><font face="Arial" size="2"><input type="text" name="State" size="2"></font></td>
</tr>
<tr>
<td width="125"><font face="Arial" size="2">ZIP Code:</font></td>
<td width="192"><font face="Arial" size="2"><input type="text" name="ZIP" size="9"></font></td>
</tr>
<tr>
<td width="125"><font face="Arial" size="2">Country:</font></td>
<td width="192"><font face="Arial" size="2"><input type="text" name="Country" size="20"></font></td>
</tr>
<tr>
<td width="125"><font face="Arial" size="2">Telephone:</font></td>
<td width="192"><font face="Arial" size="2"><input type="text" name="Telephone" size="20"></font></td>
</tr>
<tr>
<td width="125"><font face="Arial" size="2">Fax:</font></td>
<td width="192"><font face="Arial" size="2"><input type="text" name="Fax" size="20"></font></td>
</tr>
<tr>
<td width="125"><font face="Arial" size="2">E-mail:</font></td>
<td width="192"><font face="Arial" size="2"><input type="text" name="Email" size="20"></font></td>
</tr>
<tr>
<td width="125"><font face="Arial" size="2">Key Contact:</font></td>
<td width="192"><font face="Arial" size="2"><input type="text" name="KeyContact" size="20"></font></td>
</tr>
<tr>
<td width="125"><font face="Arial" size="2">Key Contact's Title:</font></td>
<td width="192"><font face="Arial" size="2"><input type="text" name="KeyContactTitle" size="20"></font></td>
</tr>
</table>
</center>
</div>
<font face="Arial" size="2">
<img src="images/space.gif" alt="space.gif (65 bytes)" width="15" height="14"></font>
<div align="center">
<center>
<table border="0" cellpadding="3" width="97" height="768">
<tr>
<td width="607" colspan="4" bgcolor="#A0CFCF" height="18">
<p align="center"><strong><font face="Arial" size="2">Expertise
and Objectives</font></strong></p>
</td>
</tr>
<tr>
<td width="607" colspan="4" height="34"><font face="Arial" size="2">In what sector of the
agro-industrial market are you most interested in expanding?</font></td>
</tr>
<tr>
<td width="607" colspan="4" height="81"><font face="Arial" size="2"><textarea rows="3" name="Expanding" cols="44"></textarea></font></td>
</tr>
<tr>
<td width="607" colspan="4" height="18"><font face="Arial" size="2">In which specific subjects is your
organization able to lend expertise?</font></td>
</tr>
<tr>
<td width="38" height="21"><font face="Arial" size="2"><input type="checkbox" name="Aquaculture" value="ON"></font></td>
<td width="264" height="21"><font face="Arial" size="2">Aquaculture/Fisheries</font></td>
<td width="41" height="21"><font face="Arial" size="2"><input type="checkbox" name="Feed" value="ON"></font></td>
<td width="240" height="21"><font face="Arial" size="2">Feed/Seed</font></td>
</tr>
<tr>
<td width="38" height="34"><font face="Arial" size="2"><input type="checkbox" name="AgChemicals" value="ON"></font></td>
<td width="264" height="34"><font face="Arial" size="2">Agchemicals/</font><font face="Arial" size="2">Fertilizers</font></td>
<td width="41" height="34"><font face="Arial" size="2"><input type="checkbox" name="Finance" value="ON"></font></td>
<td width="240" height="34"><font face="Arial" size="2">Finance/Related
Services</font></td>
</tr>
<tr>
<td width="38" height="34"><font face="Arial" size="2"><input type="checkbox" name="Bakery" value="ON"></font></td>
<td width="264" height="34"><font face="Arial" size="2">Bakery/Grain</font></td>
<td width="41" height="34"><font face="Arial" size="2"><input type="checkbox" name="FoodDistribution" value="ON"></font></td>
<td width="240" height="34"><font face="Arial" size="2">Food
Distribution/Storage</font></td>
</tr>
<tr>
<td width="38" height="21"><font face="Arial" size="2"><input type="checkbox" name="Beverages" value="ON"></font></td>
<td width="264" height="21"><font face="Arial" size="2">Beverages</font></td>
<td width="41" height="21"><font face="Arial" size="2"><input type="checkbox" name="FoodProcessing" value="ON"></font></td>
<td width="240" height="21"><font face="Arial" size="2">Food
Processing</font></td>
</tr>
<tr>
<td width="38" height="40"><font face="Arial" size="2"><input type="checkbox" name="BiogeneticEng" value="ON"></font></td>
<td width="264" height="40"><font face="Arial" size="2">Biogenetic
Engineering</font></td>
<td width="41" height="40"><font face="Arial" size="2"><input type="checkbox" name="Forestry" value="ON"></font></td>
<td width="240" height="40"><font face="Arial" size="2">Forestry</font></td>
</tr>
<tr>
<td width="38" height="11"><font face="Arial" size="2"><input type="checkbox" name="Biomass" value="ON"></font></td>
<td width="264" height="11"><font face="Arial" size="2">Biomass/AgEnergy</font></td>
<td width="41" height="11"><font face="Arial" size="2"><input type="checkbox" name="Fruits" value="ON"></font></td>
<td width="240" height="11"><font face="Arial" size="2">Fruits/Vegetables</font></td>
</tr>
<tr>
<td width="38" height="18"><font face="Arial" size="2"><input type="checkbox" name="Construction" value="ON"></font></td>
<td width="264" height="18"><font face="Arial" size="2">Construction</font></td>
<td width="41" height="18"><font face="Arial" size="2"><input type="checkbox" name="Groceries" value="ON"></font></td>
<td width="240" height="18"><font face="Arial" size="2">General
Groceries</font></td>
</tr>
<tr>
<td width="38" height="18"><font face="Arial" size="2"><input type="checkbox" name="Dairy" value="ON"></font></td>
<td width="264" height="18"><font face="Arial" size="2">Dairy</font></td>
<td width="41" height="18"><font face="Arial" size="2"><input type="checkbox" name="LandReclamation" value="ON"></font></td>
<td width="240" height="18"><font face="Arial" size="2">Land
Reclamation</font></td>
</tr>
<tr>
<td width="38" height="18"><font face="Arial" size="2"><input type="checkbox" name="Equipment" value="ON"></font></td>
<td width="264" height="18"><font face="Arial" size="2">Equipment/Implements</font></td>
<td width="41" height="18"><font face="Arial" size="2"><input type="checkbox" name="Meat" value="ON"></font></td>
<td width="240" height="18"><font face="Arial" size="2">Meat/Poultry</font></td>
</tr>
<tr>
<td width="38" height="18"><font face="Arial" size="2"><input type="checkbox" name="FarmManage" value="ON"></font></td>
<td width="264" height="18"><font face="Arial" size="2">Farm
Management</font></td>
<td width="41" height="18"><font face="Arial" size="2"><input type="checkbox" name="Sweeteners" value="ON"></font></td>
<td width="240" height="18"><font face="Arial" size="2">Sweeteners</font></td>
</tr>
<tr>
<td width="38" height="34"><font face="Arial" size="2"><input type="checkbox" name="FarmMarketing" value="ON"></font></td>
<td width="264" height="34"><font face="Arial" size="2">Farm Product
Marketing</font></td>
<td width="41" height="34"><font face="Arial" size="2"><input type="checkbox" name="Tobacco" value="ON"></font></td>
<td width="240" height="34"><font face="Arial" size="2">Tobacco</font></td>
</tr>
<tr>
<td width="607" colspan="4" height="18"><font face="Arial" size="2">Other:</font></td>
</tr>
<tr>
<td width="607" colspan="4" height="81"><font face="Arial" size="2"><textarea rows="3" name="Other" cols="44"></textarea></font></td>
</tr>
<tr>
<td width="607" colspan="4" height="18"><font face="Arial" size="2">Objective (reason for becoming a
member of The Agribusiness Council):</font></td>
</tr>
<tr>
<td width="607" colspan="4" height="81"><font face="Arial" size="2"><textarea rows="3" name="Objective" cols="44"></textarea></font></td>
</tr>
</table>
</center>
</div>
<p align="center"><input type="submit" value="Submit" name="B3"></p>
<p align="center"><input type="reset" value="Reset" name="B4"></p></form>
<p align="center"><font face="Arial" size="2"><br>
</font><img border="0" src="images/agrilogo-small.gif" width="100" height="111"><br>
</p>
<p align="center"><font face="Arial" size="2"><strong>
The Agribusiness Council<br>
P.O. Box 5565 <br>
Washington DC 20016</strong></font></p>
<p align="center"><b><font face="Arial" size="2">Tel:</font></b><font face="Arial" align="center" size="2"><b>
(202) 296-4563</b></font></p>
<p align="center"><b><font face="Arial" size="2">
[email protected]</font></b></p>
<p align="center"> </p>
<p align="center">
<font face="Arial" size="2"><a href="default.htm">Home</a></font></p>
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