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Farmer Registration Form
1.) Name of Farm:
*
2.) Contact Person:
*
First
Last
3.) Phone:
*
Area Code
-
Phone Number
4.) E-mail:
*
5.) Mailing Address:
*
Street Address
City
State / Province / Region
Postal / Zip Code
6.) Physical Address:
*
Street Address
City
State / Province / Region
Postal / Zip Code
7.) Offer Direct Delivery?:
*
Yes
No
8.) If so, how far?:
9.) Current Distributor(s) Used:
*
10.) Number of Acres:
*
11.) Interested in Pres-Sales / Grow Out Contract?
*
Yes
No
12.) Liability Insurance Info:
*
13.) Certifications:
*
14.) Other Products (Besides Produce):
15.) Top Crops Produced in Summer/Fall (What + # of Pounds):
16.) Top Crops Produced in Winter (What + # of Pounds):
17.) Top Crops Produced in Spring (What + # of Pounds):
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