NAME

ADDRESS

CITY

COUNTY

STATE Zip

Phone - -

E-Mail

Check Occupation (check all that apply)

Grower

PCA

Packer/Processor

Research/Gov/Ed

Assn/Commission

Supplier/Mfg/Svc

Ad Agency

Other

List Acreage Totals - (all fields must be filled in. Use a zero where you have no acreage)

Artichoke / Asparaus / Beans / Beets /

Bell Pepper Bokchoy / Broccoli / Cabbage

Cantaloupe / Carrots / Cauliflower / Celery

Chard / Collard / Corn / Cucumber

Eggplant / Endive / Garlic

Greens / Herbs / Kale / Lettuce

Leeks / Melons / Mushrooms / Okra

Onions / Peas / Peppers / Potatoes

Pumpkins / Radish / Rape / Seed

Spinach / Squash / Strawberries / Tomatoes

Turnip / Watermelons / Yams

Please Answer Personal Question below for verification Purposes

What High School did you graduate from?