Produce Safety

Produce Safety Rule Exemption Application

If you have completed the initial Exemption Application in previous years, please fill out either the Basic Exemption Renewal or the Qualified Exemption Renewal, whichever is applicable.

Farm Information

Farm Name:
Physical Address:
Physical Zip:
Physical City:
Physical State:
Farm Phone:
Farm Email:

Mailing address same as physical address:

Mailing Address:
Mailing Zip:
Mailing City:
Mailing State:

Name of Farmers Market where produce is sold:

Contact Information

Contact First Name:

Contact Last Name:

Contact Phone:

Contact Email:

Other Information

Farm Size Based On Average FOOD Sales (in the past 3 years): * Food Sales – includes all food for humans, feed for animals, & sales of live food animals

Number of water sources per source type:

Protected Well:
Surface Water:
City or Rural Water:
Other:

Does your Farm use Soil Amendments of Animal Origin (ex. Chicken Litter)?

Please fill in your growing season:

Plant Date:

Harvest End Date:

Produce Safety Rule Exemption Application

If you have completed the initial Exemption Application in previous years, please fill out either the Basic Exemption Renewal or the Qualified Exemption Renewal, whichever is applicable.

Farm Information

Contact Information

Other Information

Number of water sources per source type:

Does your Farm use Soil Amendments of Animal Origin (ex. Chicken Litter)?

Please fill in your growing season:

Acreage:

Please check all that applies to your farm:

List of crops grown, harvested, packed and held:

Covered Produce (Check all boxes for Covered Produce that you grow)

Non-Covered Produce (Check all boxes for Non-Covered Produce that you grow)

Has your company taken the PSA grower training class?

Would your company like an On-Farm Readiness Review?