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): ✻
Other:
Occupation (Check all that apply):
Crops:
Number of acres:
Gender (optional):
Ethnicity (optional):
