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Last Name __________________________________________________

First Name _________________________________________________

Address

     _______________________________________________________

     _______________________________________________________


Phone ______________________________________________________


E-mail _____________________________________________________


Fax ________________________________________________________


Agricultural or forestry producer?  ___

Price: $56.98 (taxes included)


Rural resident or retired farmer?  ___

Price: $56.98 (taxes included)


Previous QFA Member?         Yes ___     No ___


Type of production: ________________________________________


Signature: _________________________________________________

GST No.  107 867 814 RT 001
QST No.  100 611 322 9 TQ 001

Please enclose cheque payable to Quebec Farmers’ Association.
Do NOT send cash in the mail. Receipts are issued upon request.

Quebec Farmers' Association (QFA)
555 Boul. Roland-Therrien,
Office 255,
Longueuil, QC
J4H 4E7

Phone: 450-679-0540 Ext. 8536
Fax: 450-463-5291
Email: qfa@upa.qc.ca