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
OwnerFood Safety ManagerOperatorEmployeeOther (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
OwnerFood Safety ManagerOperatorEmployeeOther (please describe)
FARM PRODUCTION INFORMATION
Grow ProduceHarvest ProducePack ProduceHold Produce
Less than $25,000$25,000 - $250,000$250,000 - $500,000More than $500,000
YesNo
YesNo
YesNo
Ground Water (Well Water)Surface Water (Pond Water)City/Rural water districts
0-1011-1516-2021-5051-100101-499500-9991000+
Already EstablishedYear RoundJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Year RoundJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Yes, all of my produce is for personal consumptionSome, but not all of my produce is for personal consumptionNo, all of my produce is sold to others
Yes, all of my produce will undergo some type of commercial processing that includes a “kill step”Yes, some of my produce will undergo some type of commercial processing that includes a "kill step"No, none of my produce will undergo some type ofcommercial processing thatincludes a “kill step”
ApplesApricotsApriumsAsian pearsAsparagusBabacosBasilBelgian endiveBlack beansBlackberriesBlueberriesBoysenberriesBrazil nutsBroad beansBroccoliBrussel sproutsBurdockCabbagesCantaloupesCarambolasCarrotsCashewsCauliflowerCeleriacCeleryChayote fruitCherriesChestnutsChickpeasChicory (roots and tops)Chinese cabbages (Bok Choy, mustard and Napa)ChivesCilantroCocoa beansCoffee beansCollardsCowpea beansCranberriesCucumbersCurly endiveCurrantsDandelion leavesDatesDill (seeds and weeds)EggplantsFigsFlorence FennelFood grains (such as barley, dent- or flint-corn, sorghum, oats, rice, rye, wheat, amaranth, quinoa, buckwheat, & oilseeds)Garden beets (roots and tops)Garden cressGarlicGenipGingerGlobe type antichokesGooseberriesGrapefruitGrapesGreat Northern beansGreen beansHazelnutsHoneydewHorseradishHuckleberriesJerusalem artichokesKaleKidney beansKohlrabiKumquatsLeekLemonsLentilsLettuceLima beansLimesMandarins (such as Clementines or Tangerines)MayhawsMelons (such as Canary, Crenshaw, and Persian)Microgreens (Varieties)MulberriesMuscadinesMushroomsMustard GreensNavy beansNectarinesOkraOnionsOrangesOreganoPapayaParsleyParsnipsPassion FruitPeachesPeanutsPearsPeasPecansPeppermintPeppers (such as bell and hot)PersimmonsPigeon peasPine nutsPinto beansPlumsPlumcotsPluotsPomegranatesPotatoesPumpkinsQuinceRadishesRaspberriesRhubarbRutabagasSageScallionsShallotsSnow peasSour cherriesSoursopSpinachSprouts (such as alfalfa and mung bean)StrawberriesSugar BeetsSummer squash (such as patty pan, yellow and zucchini)Sweet cornSweet potatoesSweetsopSwiss chardTangorsTaroThymeTomatoesTumericTurnips (roots and tops)WalnutsWater chestnutsWatercressWatermelonsWinter squashYams
Does your farm grow, harvest, pack, or hold any produce not included above? Please list below. Mark N/A, if not applicable.*

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FARM PRODUCTION INFORMATION