Name *

First Name

Last Name

Phone Number

(###)

###

####

Farm Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is your farm *

Irrigated

Non-irrigated

When were pesticides last used on your farm? *

Within the last 10 years

Over 10 years ago

Do neighbouring farmers use pesticides?

Yes

No