Reduced Rate Registry Application

Name *

First

Last

Email *

Contact Phone Number *

Best Time to Call *

Mailing Address *

If shipping is different than billing, please fill out shipping address.

Shipping Address

Emergancy Contact *

Name and number required

Are You Employed? *

If so, please fill out the below employment information.

Employer Name

Employer Phone Number

Position with Company

Applicant Income *

Please provide a breakdown of income sources. For example: $400 from Social Security, $300 from Disability Benefits, $200 from Employment

Spousal Income

Total Income *

Do you Receive Disability of Social Security? *

Yes, both.
Yes, disability.
Yes, social security.
No.

Reason Why You Qualify *

you Number Employed?

List Any Skill(s) that you would be able to offer/hourly rate

Here at Rush Hemp Farms, we offer the agriculture LETS (local exchange trading system)! This is NOT intended to trade items, but to trade your skills and time for a return in helping others.

E-Sign *

Please input your full name.