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  1. Complete the printed form.
  2. Return by either:
Mail to: Florida Farm Bureau
PO Box 147030
Gainesville, FL  32614-7030
FAX: 1-352-374-1577
Or: You may drop this completed form at your local County Farm Bureau office.

Authorization and Agreement for Recurring Credit Card Payments

I have read and agree to the Terms and Conditions for Recurring Premium Payments via the Credit Card account as designated below.  By signing this form, I authorize Florida Farm Bureau to initiate through the designated financial entity the appropriate entries to transfer premium payments.  I understand that if I want to cancel the transfer so authorized below, I must notify Florida Farm Bureau in writing no later than three (3) business days prior to the date of transfer. 
Credit Card Number ____________________________________ Exp. Date _____________

Name exactly as printed on credit card ________________________________________

Credit Card Account Billing Address ___________________________________________

City _____________________________________   State ______   ZIP _______________

Florida Farm Bureau Account Number ____________________________________________

Signature _______________________________________________  Date _______________

Daytime Phone _______________________ E-mail (optional) _______________________