NAME OF FIRM OR ORGANIZATION*

REPRESENTATIVE’S EMAIL ADDRESS*

DESIGNATED REPRESENTATIVE

REPRESENTATIVE’S TITLE

BUSINESS TELEPHONE

BUSINESS FAX

IF YES, OF WHICH EXCHANGE ARE YOU A MEMBER?

BUSINESS WEBSITE

MEMBERSHIP TYPE SOUGHTFULLASSOCIATE

ARE YOU A MEMBER OF A RECOGNIZED GRAIN EXCHANGE IN THE UNITED STATES AND/OR THE DOMINION OF CANADA?YESNO

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PLEASE GIVE A BRIEF DESCRIPTION OF YOUR BUSINESS.