INITIAL CERTIFICATION REQUEST

OperationName:Authorized Operator(s)Name: Phone:

Is this a new site to add to a current certification?Yes No

*If adding to existing NOP certification an estimate of additional costs will be provided

Sole Proprietor/Individual? Yes No

If no, please attach documentation of legal entity status (ex: articles of incorporation, by-laws, ownership, membership provisions)

Email Address:

Mailing/ BusinessAddress:

Site address(es) to be inspected (if different):

Additional sites to be inspected:Yes No

Subcontractor used:NoYesIf yes for which activity:

Type of Service Requested: National Organic Program USDA ECOCERT Transitional Certification

Shipping under USDA NOP equivalency arrangement requires issuance of Certificates of Inspection (Export Certificates) for any of these countries: No Yes (If Yes, please select):

EU JAS (Japan)SwitzerlandCOR (Canada) Korea Taiwan

Please describe timeframe requested or date of first harvest:

Expedited Service (Approximately 8 weeks)Yes No

Have you been referred to us by one of our client(s)? NoYes (If yes please specify name)

Are you a Veteran? Yes No

Current certification status:

New applicant (not currently certified)

Reinstatement applicant (currently suspended by any certifier)

ECOCERT ICO certified applicant

Certified applicant, other certifying agency(please list if certified currently or surrendered in the past):

Date of First Certification (Renewals or transfers only, certification must be held continuously from this date, no matter which certifier):

Have you ever been certified by another organic certification agency?Yes No

If yes, please identify the agency and dates below:

Have you ever been denied, suspended, or had your certification revoked? Yes No

Have you ever been “responsibly connected” to any operation whose certification has been denied, suspended, or revoked? “Responsibly connected” means “affiliation as individual owner, partner in a partnership, member, manager, officer, director or holder of more than a 10 percent ownership stake in a limited liability company, or officer, director or holder of more than 10 percent of the outstanding stock of a corporation or association.” Yes No

(1)Crops

Aquaponic/Bioponic/Hydroponic or container Production?Yes No

Maple syrup production?Yes No

Number ofAcres Non Organic and Organic if applicable: Non OrganicProposed for Organic

List ofCrops:

On Farm Processor? Operations which (1) handle or process only their own crops for their own use. For example: cleaning seeds, feed processing for their own livestock or (2) which have a simple process with their own crops but are selling the resulting product off farm. In that case, product must be kept in the same condition as it was during the harvest. For example: cleaning and packaging, cooling storing their own fruits,dryinggrain. Yes No

Split Operation: Do you process both organic and non-organic products?Yes No

(2)Livestock

Number of AnimalsProposed for Organic: Cattle:DairyCow: Goats: Hogs: Poultry:

Other (please specify types of animals andnumbers):

Number of AnimalsNon Organic: Cattle:DairyCow:Goats: Hogs: Poultry:

Other (please specify types of animals andnumbers):

On Farm Processor? Operations which (1) handle or process only their own products for their own use or (2) operations which have a simple process with their own products but are selling the resulting product off farm-e.g. cooling and storing milk, washing and packaging eggs, initial fiber processing to prepare product for use or sale: Yes No

Split Operation: Do you process both organic and non-organic products?Yes No

(3)Handler

Simple processor (process single ingredient products or repackaging single ingredient products)

Complex processor (multi-ingredient products)

Retailer (sell to final consumer – no processing or repackaging)

Distributor (sell to other businesses or retailers – no processing or repackaging)

Distributor with its own label (uses its own brand with his name and certification agency)

Other(specify):

Products:

NumberofProducts: Type of product:

Split Operation: Do you process both organic and non-organicproducts?Yes No

Please provide a brief summary of your operation and any other additional notes below. (i.e. any on-farm activities specifically performing)

Approval / Form’s code / Last update
QM / F8 (v7) (f) / 06/28/17

Return formto: ax: 317-708-0628