TEXAS CERTIFIED FARMERS MARKET CORPORATION STORE INSURANCE APPLICATION Name of Association ______________________________________________________ Contact Name _____________________________________________________ Name of Member ______________________________________________________ Address ______________________________________________________ City & State ______________________________________________________ Telephone ___________________ Email ______________________________ Name of Store _______________________________________________________ Address _______________________________________________________ City & State _______________________________________________________ Contact Name _____________________________________________________ Telephone ___________________ Email ______________________________ We the undersigned being duly elected officers/directors of the above named Association, do hereby certify that ________________________________ is currently a member in good standing and was also a member in good standing during he previous year. ____________________________ ______________________ Name Title ____________________________ ______________________ Name Title I, ______________________________, do hereby certify that I have had no product liability claims during the previous three years. Please include one application and payment of $80.00 for each producer and store to be covered, i.e., one producer who wants coverage for 2 stores must submit 2 applications and pay $160.00. Please return completed application and payment to: |
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