QID 002009 2019 Fruit Chemical Use Survey Chemical Applications Con

Non-substantive change request to Maryland Pesticide Use Survey

0218 - Chemical Applications Consent Form - Fruit

Agricultural Resource Management, Chemical Use, and Contractor Expense Surveys

OMB: 0535-0218

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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: ____________________________________________________




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AuthorCarol Pinto
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