Revised 3-27-12

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APPLICATION Club Master Participant Store/Dealer________________________________________________________________________ Name____________________________________ Age__________Birthdate____________________ Signature __X________________________________________________________________________ Address:_________________________________________County:_____________________________ City/State/Zip:________________________________________________________________________ Email address:________________________________________________________________________ Name of 4-H Club/F. F. A. Chapter:________________________________________________________ Name of 4-H Club Leader/F.F.A. Chapter Advisor:____________________________________________ T-shirt size: Youth – Small______________Medium___________________Large__________________ Adult – Small________Medium________Large________XLarge_________XXLarge_______ Qualifications: 1. Exhibitor must be 21 years of age or younger 2. Exhibitor must feed Southern States feeds exclusively produced in a Southern States Cooperative Feed Mill (complete feed or supplement) 3. Only one county/district championship allowed per exhibitor and animal 4. Exhibitor eligible to compete in home county/district and state only 5. Entry must be completed 60 days or more before show date The following is to be submitted to your local dealer in order to receive any proceeds from program: 1. Weight ticket 2. Photo of you and entry animal at show 3. Confirmation of win (show official such as F.F.A. Advisor, Agriculture Extension Agent or Newspaper) 4. Claims must be filed with local store/dealer within 60 days after show.Once a Southern States employee has reviewed the program with the participant and the participant agrees to the above rules, a personalized Southern States/Club Master hat will be sent to the Store Manager for the Club Master participant.

Store Manager signature:________________________________________ Date_______ Store Manager should sign this form and mail to Charlotte Layne at P.O. 26234, Richmond, Virginia 23260. Hats will be returned to the Store Manager in three weeks. Store Manager should keep a copy for their records. Revised 7-8-13. Form can be found on StatesNet/Sales Promotion/Rewards Program