BEULAHLAND FARM
2009 12 WEEK CSA SUBSCRIPTION FORM
(Please print legibly or type)

NAME(S)_______________________________________________________________

ADDRESS______________________________________________________________

CITY/STATE/ZIP_________________________________________________________

HOME PHONE__________________________________________________________

WORK PHONE__________________________________________________________

CELL PHONE___________________________________________________________

E-MAIL________________________________________________________________

I WILL PICK UP MY SUBSCRIPTION EACH SATURDAY  BETWEEN 8:00 AM AND NOON, AT THE BEULAHLAND FARMSTAND LOCATED AT:

The Village Pointe Farmers Market, 168 & West Dodge Rd.

PAYMENT:

____$300.00 full subscription payment enclosed.

____$100.00 non-refundable deposit enclosed ($200.00 balance due by May 1, 2009).

____$48.00 additional 12 week dozen egg subscription (due by May 1, 2009).

____$27.00 additional 12 week half-dozen egg subscription (due by May 1, 2009).

Total Enclosed $__________

I have read and understand the Subscriber – Grower Agreement 2009 and hereby agree to its terms.

Mail checks payable to Beulahland Farm to:

Victor Novak
Beulahland Farm
2011 County Rd. Q
Lyons, NE 68038