Send Completed Applications to: Washington State Dept. of Agriculture Plant Services Program PO Box 42560 Olympia, WA 98504-­‐2560 (360) 902-­‐1874 Fax: (360) 902-­‐2094 Application for Inspection -­‐ SERF (Socially & Environmentally Responsible Farms) Participation is voluntary All applications for the current season must be received by August 1st GROWER/COMPANY NAME CONTACT PERSON PHONE NUMBER GROWING SITE ADDRESS FIELD CONTACT PHONE NUMBER CITY STATE GPS COORDINATES ZIP BILLING ADDRESS Lat: Long: EMAIL CITY STATE ZIP FAX NUMBER VARIETIES PLANTED HARVEST DATE (MM/DD/YYYY) ACRES TO INSPECT COMMENTS It is your responsibility to notify the WSDA inspector of any pesticide applications made immediately before or during the inspection period, as required by the State of Washington or pesticide labeling. I request and grant permission to WSDA inspectors to access the listed growing site property for purposes of SERF inspections and auditing. I have a SERF Sustainability Plan in place and agree to follow and update it. I understand that I will be charged for the inspection services at the current hourly and mileage rates as established by WAC 16-­‐470. I agree to pay all charges billed at the time of service. APPLICANT'S SIGNATURE DATE Additional information is available at the SERF website: SERFcertified.org. AGR FORM 816-­‐6103 (R/10/9/12) Page 1 of 1