Printed: September 30, 2012 Land Use History Verification I Applicant Information and Description of Land Parcel(s) Applicant: Field ID(s): Legal Description Of Property (township – range – section): Field acreage (total): II Responsible Entity Have you owned or managed the land seeking organic certification for the last 36 months? Yes (please skip to section 3) No (please have the previous owner/land manager complete the following information. Both the applicant and the previous manager must complete and sign this form) Previous Land Manager Name: Previous Land Manager Mailing Address: City: State: Zip: Previous Land Manager Phone Number(s): AESOP 9602; ISSUE 2; STATUS-PUBLISHED; EFFECTIVE 19 OCT 2010 Page 1 of 2 Copyright QAI, Inc. The contents of this document, including format, style, and wording, are the property of Quality Assurance International (QAI). No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, without written permission (except for the express purpose of preparing and transferring information to QAI in execution of a certification program). Reproduction or translation of any part of this work without permission of the owner is unlawful. QAI, the QAI logo, and Quality Assurance International are registered trademarks of QAI, Inc. Printed: September 30, 2012 Name of Applicant:_____________________________________ III Land Use History Please list ALL inputs applied in the last 36 months to the fields seeking certification. Crops grown each year must also be listed in order to illustrate crop rotations, if applicable. This input list must include fertilizers, herbicides, pesticides, fungicides, seeds (including treated seeds) as well as all other input materials and the dates of application. If inputs were not applied to respective fields during the last three years, please clearly state “none” in this section of the form. You may attach a separate page. Field ID Acres Year:__________ Year :___________ Year: __________ Crops or land use Input/Date Applied Crops or land use Input/Date Applied Crops or land use Input/Date Applied IV Notarized Declaration I, , declare that the parcel(s) of land described above were farmed by me or were under my control during the crop years of to . I also declare that during this time, to the best of my knowledge, there were no herbicides, pesticides, fungicides, seed treatments, synthetic fertilizers, or other materials applied to this land other than those approved under the applicable regulation (circle the applicable certification program[s]): National Organic Program [NOP] EC 834/2007 and EC 889/2008 Canadian Organic Regime JAS Other I submit that the above information is true and accurate. *** Please have this document verified by a Notary Public. *** Applicant Name (printed): Applicant Signature: Date: Prior Land Manager Name (if applicable) Signature (Prior Land Manager): Date: _______ AESOP 9602; ISSUE 2; STATUS-PUBLISHED; EFFECTIVE 19 OCT 2010 Page 2 of 2 Copyright QAI, Inc.
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