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✻ = Required

First Name:✻

Last Name:✻

Business Name or Affiliation:✻

Street Address or P.O. Box:✻

City:✻

State:✻

Zip Code:✻

Phone Number:✻

Email:✻

County where you farm or serve (check all that apply):✻

Colusa Sutter Yuba Other

Other:

Occupation (Check all that apply):

Farm Owner/Operator Farm Manager PCA Government University Non-Profit Other

Crops:

Number of acres:

The following questions are optional. You are being asked for this information because ANR has certain obligations as a federal contractor to report the gender and ethnicity of the people it serves. Your choice will be kept strictly confidential, and you will not be individually identified with your designation in any public report or forum. This information will only be used in the aggregate for federal reporting purposes.

Gender (optional):

Ethnicity (optional):

White Black Hispanic Asian/Pacific Islander American Indian/Alaskan Native

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