QID 002009 2019 Fruit Chemical Use Survey Chemical Applications Con

Project 141 QID 002009			OMB No. 0535-0218 Approval Expires XX/XX/XXXX
	2019 Fruit Chemical Use Survey Chemical Applications Consent Form					NATIONAL AGRICULTURAL STATISTICS SERVICE
				U.S Department of Agriculture Rm. 5030, South Building 1400 Independence Avenue, S.W. Washington, D.C. 20250-2000 1-800-727-9540 Fax: 202-690-2090 Email: [email protected]

The National Agricultural Statistics Service (NASS) of the U.S. Department of Agriculture is conducting a survey of the Fruit Chemical Usage for the 2019 crop year. The survey will be conducted from October 2019 through January 2020.
By signing this Consent Form, the Owner agrees to allow the fruit caretaking company listed below to provide the necessary information for the completion of the Fruit Chemical Use Survey for the selected operation to the National Agricultural Statistics Service. All information provided is voluntary and held strictly confidential. Results of the survey, showing State and National level results for the selected fruit will be available at the end of July 2020.
	Operation Name:	_____________________________________________________________________
	Owner Name:	_____________________________________________________________________
	Owner Address:	_____________________________________________________________________
		_____________________________________________________________________
	Owner Signature:	_____________________________________________________________________
	Date:	_________________
	Fruit Caretaking Company Name:	_____________________________________________________________________
	Fruit Caretaking Company Address:	_____________________________________________________________________
		_____________________________________________________________________
	Phone Number:	_________________________________

NASDA Field Enumerator: ____________________________________________________