This form must be completed by the previous owner/manager for land being requested for organic certification. Name of person completing this form: Name of person/operation requesting organic certification: I, . affirm that the parcel(s) of land described below were farmed/ranched by me or were under my management and control during the following dates: . – I also affirm that during this time, to the best of my knowledge, there were no herbicides, pesticides, fungicides, fungicide treated seed, synthetic fertilizers, or other prohibited materials applied to this land. Field # Acres Location How Land Was Used Last Nonorganic Input (County, Township, Range, (pasture, CRP, cropped, etc.) and Date Applied Section or Street Address) Signature: Date: Name (printed)
This form must be completed by the previous owner/manager for land being requested for organic certification. Name of person completing this form: Name of person/operation requesting organic certification: I, . affirm that the parcel(s) of land described below were farmed/ranched by me or were under my management and control during the following dates: – . I also affirm that during this time, to the best of my knowledge, there were no herbicides, pesticides, fungicides, fungicide treated seed, synthetic fertilizers, or other prohibited materials applied to this land. Field # Acres Location (County, Township, Range, Section or Street Address) How Land Was Used (pasture, CRP, cropped, etc.) Last Nonorganic Input and Date Applied Signature: Date: Name (printed)