Application for 2013 SWAT (Strength with Advisory Teams)

ILLINOIS FARM BUREAU Application for 2013 SWAT (Strength With Advisory Teams) --Please type or print clearly--

Please return completed application by DECEMBER 6 to: Mary Kobbeman PLEASE COMPLETE ENTIRE APPLICATION IF Illinois Farm Bureau YOU WISH TO BE CONSIDERED FOR A TEAM. 1701 Towanda Avenue Bloomington, IL 61701 Fax: 309-557-3729

TODAY'S DATE COUNTY OF MEMBERSHIP I will be able to attend the January 31, 2013 meeting: YES  NO   Mr. FIRST NAME MIDDLE NAME LAST NAME SUFFIX PREFERRED NAME  Mrs.  Ms. ADDRESS CITY ZIP + 4

PRIMARY EMAIL TELEPHONE

MOBILE: (______)______ Mobile is used as primary phone. HOME: (______)______

PLEASE HELP US ASSIGN YOU TO THE TEAM OF GREATEST INTEREST TO YOU. THE THREE TEAMS ARE LISTED BELOW. PLEASE NUMBER YOUR FIRST, SECOND, AND THIRD CHOICE. (See SWAT brochure for team issues.)

_____ Farming Production and Marketing _____ Local and State Government ____ Conservation and Natural Resources

WHY YOU WOULD LIKE TO BE A TEAM MEMBER?

WHAT IS YOUR OCCUPATION?

WHAT POLICY ISSUES SHOULD FARM BUREAU BE ADDRESSING IN THE NEXT FIVE YEARS?

LIST COMMODITY, COMMUNITY, OR PROFESSIONAL AFFILIATIONS (OTHER THAN FARM BUREAU) AND POSITIONS HELD.

LIST ANY EXPERIENCES YOU MAY HAVE IN COMMUNITY, LEGISLATIVE, OR REGULATORY INITIATIVES/ACTIVITIES (i.e., attending local hearings, engaging in efforts to address a local issue, dialoguing with elected officials, educating others on agriculture, etc.).

(continued on back side) PLEASE INCLUDE ANY ADDITIONAL TRAINING OR WORK EXPERIENCES YOU HAVE.

ADDITIONAL COMMENTS:

AD HOC ADVISORY GROUPS

PLEASE NOTE THAT DUE TO LIMITED SPACE, NOT ALL INDIVIDUALS WILL BE SELECTED TO SERVE ON A TEAM.

YOUR INPUT IS STILL NECESSARY TO HELP GUIDE THE ORGANIZATION. IF YOU ARE INTERESTED IN SERVING AS A RESOURCE WHEN ISSUES ARISE IN ANY OF THE FOLLOWING AREAS, PLEASE CHECK ALL AREAS BELOW THAT APPLY:

COMMODITY INTERESTS: OTHER INTERESTS: (905)  Renewable Energy (500) (910)  Aquaculture (800)  Agriculture in the Classroom  Rural Health (505) (915)  Beef Cows (805)  Agri-Tourism  Rural Life (510) (920)  Breeding Hogs (810)  Animal Welfare  School Boards (515) (925)  Corn (815)  Biotechnology  Secondary Ag Education/FFA (520) (930)  Dairy Cows (820)  Conservation Initiatives  Specialty Crops (525) (935)  Feeder Cattle (825)  Consumer Education  Taxes (530) (940)  Fruit and Nuts (830)  Education  Telecommunications (535) (945)  Greenhouse, Nursery & Floriculture (835)  Energy  Transportation (540) (950)  Hay (840)  Farm Safety  Utilities (545) (955)  Horses/Equine (845)  Food Safety  Value Added Products (550) (960)  Market Hogs (850)  Government Farm Policy  Water Quality and Quantity (555) (965)  Oats (855)  International Trade  Wildlife & Recreation (560) (970)  Poultry & Eggs (860)  Labor  Youth/4-H (565)  Sheep & Goats (865)  Land Use (570)  Sorghum (870)  Local Government ELECTED/APPOINTED OFFICE(S) (575)  Soybeans (875)  Local Food Initiatives HELD: (580) (202)  Vegetable Crops (880)  Marketing  County Official (585) (204)  Wheat (885)  Political Campaign Involvement  School Board (590) (206)  Winery/Grapes (890)  Public Relations  State Legislature (595) (208)  Other Crops (895)  Quality of Life  Township Official (600) (210)  Other Livestock (900)  Risk Management  Local Government

Information obtained will be used in accordance with the Illinois Farm Bureau® privacy policy, a copy of which is available on our Web site at www.ilfb.org.

For Office Use Only: Membership ID: ______

Date Voting FB ACT IFB Board Team Y / N Y / N Received: Member? Member? District: Assignment: