FARM VERIFICATION QUESTIONNAIRE

Farm Name
Farm Physical Street Address
City
State
Zip Code
Parish
Farm Mailing Address: (if different from physical address)
Street Address
City
State
Zip Code
Parish
Full Name (Point of Contact)

First NameLast Name
Phone Number
"Enter Numbers Only"Format: (000) 000-0000.
Email Address
example@example.com
Role on Farm (Check all that apply)

Other (please describe)
If your farm has an alternate point of contact, please provide their information below.
Full Name (Alternate Contact)
Phone Number
"Enter Numbers Only"Format: (000) 000-0000.
Email Address
example@example.com
Role on Farm (Check all that apply)

Other (please describe)
FARM PRODUCTION INFORMATION
On-Farm Activities (Please check all that apply)
Average annual gross produce sales for the last three years: (Select only one)
Do you sell the majority of your produce directly to consumers (Farmers' Markets, roadside stands), restaurants, or grocery stores that are within 275 miles of your farm or within the state of Louisiana?
During the previous 3 year period, were your average food sales less than $500,000? (Food sales include the sales of produce, processed food, hay, and commodities such as food grains, dairy and livestock.)
Does your farm use soil amendments of animal origin? (e.g., manure)
Type(s) of water sources used on farm (Select all that apply)
Approximate Acreage (Select only one)
Typical Planting Period (Select all that apply)
Typical Harvesting Period (Select all that apply)
Is your produce for personal/on-farm consumption?
Is your produce intended to be used in commercial processing? (i.e., canning, distilling, baking or some other action that includes a kill step)
Please place a (x) next to produce that your farm grows, harvests, packs or holds.
Does your farm grow, harvest, pack, or hold any produce not included above? Please list below. Mark N/A, if not applicable.

0/100
Should be Empty:

FARM PRODUCTION INFORMATION