Name Applicant’s Date of Birth Primary Residence Address City, State, Zip, County Applicant’s Social Security Number Spouse Name & Occupation Farming Operation (City, State, County) Mobile Phone: Email Describe Farm Operation: Acres Owned: Acres Rented: Crops Grown: # livestock raised: Other: Business experience last five years, including principal occupation & employment: Provide a brief description of any relationship, transaction or activity that would constitute a conflict of interest with the institution: Educational background: List all director positions currently held (state name of entity, location, and principal business activity): Civic, church, community activities: Elected public office currently held: Previous and present Farm Credit System service: Nominating Committee requests you complete the following questions: Please share your reason for wanting to become an AgHeritage Farm Credit Services board member. Please share what you feel are critical issues that AgHeritage Farm Credit Services should consider during the next four years. List the names of any immediate family member and affiliated organizations (any organization of which you are a partner, officer or majority shareholder) who had transactions with AgHeritage Farm Credit Services any time during the year. List the names of any immediate family member who is currently employed by a Farm Credit institution. Provide a brief description of any relationship, transaction or activity that would constitute a conflict of interest with the Farm Credit institution. I certify that the information contained in this statement is true, accurate, and complete to the best of my knowledge. I also understand that in order to be accepted as a nominee I must submit or have on file current balance sheet and the past three years earnings history information dated no later than December 31, 2023. Signature: Sign above Date: To Be eligible to serve as a Director, prospective candidates must meet the following requirements:Must be a holder of voting stock;A bona fide farmer, rancher, or producer or harvester of aquatic products;Reside or farm in the territory of the Association;Have an active loan balance with the minimum required $5,000 balance;Have an acceptable credit classificationMay not have been an employee of a System institution within one year of electionMay not serve as a director, officer, employee or agent of a financial institution or other entity that engages directly in the business of providing financing or related services products that are offered by the association CAPTCHA Get new captcha! What code is in the image? Enter the characters shown in the image. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
