4-H and FFA Discount Application

Participant's First Name *

Participant's Last Name *

Email *

Phone Number *

Participant's Birthdate *

Zip Code *

City *

State *

Which JAX store location would you like to pick up the discount coupon when ready? *

4-H or FFA Group Information

4-H or FFA Group Name *

Leader or Advisor's First Name *

Leader or Advisor's Last Name *

Leader or Advisor's Email *

County You're Showing In *

Date of County Fair *

Animals to be Shown or Project Topic *

To help us better server you, please select the animals that you will be showing at fair this year or enter your project topic under "Other".

Other Project *

Terms and Conditions *

By checking this box, I agree to the Terms and Conditions below.

I certify that I have answered truthfully and have not knowingly withheld any information relative to my application. I understand that any misrepresentation or material omission of this application will result in my being eliminated from further consideration. I further understand that, if my application is accepted, any misrepresentation or material omission which becomes known to JAX Mercantile Co. will result in immediate termination of my discounts. Discounts are limited to use by 4-H & FFA Members Only. Leaders, Parents or Members older then 19 do not qualify for the program. If Members, Leaders or Parents are found to be abusing the program, their account/discount will be canceled immediately and any balance owed will be due in full. 4-H and FFA Members will be opted in to email and marketing communications, but can opt out at any time.