AfriCert / Application for Rainforest Alliance Audit Services (Farm)
  1. GENERAL INFORMATION ON THE ORGANIZATION SEEKING CERTIFICATION

How to fill in the form:
If you see a grey field after the title or text, such as this one, please click with the mouse on this grey field and write you r text there- it will be written in the right font. In tables use the empty lines and add additional table lines if necessary (table/add/lines). In the selection-boxes, simply click on your selection and an “X” will appear.
NB:Please fill out all the blank areas in the form. Complete this form in print, typed or in any other electronic format and send it to and Incomplete forms will be returned to the sender for proper filling.
Legal name of the organization seeking certification / Legal registration N
Legal mailing address
Farm name, trade name, or d/b/a name (how the farm is commonly known)
Preferred name to be used on the audit report and certificate
Type of legal organization: (Select the appropriate type) / Company/Corporation with shareholders
Government farm
Family farm / Co-operative
Leased farm
Other, please describe:
Contact person for certification / Owner or legal representative signing legal agreements
Name / Name
Position / Position
Telephone / Telephone
Email / Email
Sales representative (contact person for product traceability processes)
Name / Telephone
Position / Email
Audit level applied for / Level C / Level B / Level A
Type of audit requested (select one): / Pre-audit / Certification audit / Surveillance 1
surveillance 2 / Preferred audit date:
Define the resources the farm can provide during the audit: / Audit team’s transportation to the farm (within the country)
Audit team’s accommodation
Audit team’s meals
If the organization has been audited previously, have there been any changes since the last audit that affect the audit scope (i.e., changes in land area or crops)? / Yes (please specify): / No
Is the farm certified or verified with any other organization? / Yes / No
If YES, please check all current valid certifications or verifications: / UTZ Certified / Organic / Global Gap
Fairtrade / 4C Association / Other (specify):
Has the farm previously been Rainforest Alliance Certified TM ?
Yes / (If YES, provide the former certificate number and the time period during which the farm was certified):
Name of the certification body: / No
Does the organization own or manage other farms not included in the scope of the audit?
Yes / (Specify) / No
Does your farm use the Rainforest Alliance Certified Seal on product or off-product? / Yes / No
  1. FARM LOCATION

Town or city / Municipality / District
County / Province, State, or Department / Country
Physical address / Please provide the street address and directions to the farm.
Location coordinates: coordinates must be taken at a point within the farm for which certification is requested. Please provide latitude and longitude coordinates in decimal degrees with five decimal places.
Latitude: / Longitude: / Altitude (meters): / Highest point
Lowest point
Location of the reading: / Describe where this coordinate was recorded (e.g. main road through member farms).
Farm boundaries (not mandatory but strongly recommended to facilitate the audit process). Please provide a shapefile or KML file indicating the farm boundaries. / Provide link here, or e-mail file to the certification body
  1. FARM AREAS AND LAND USES

Please provide the following information for the total area of the farm within the certificate scope.

Total area of the farm for which certification is requested / Area (ha)
Total area designated for agricultural crops / Area (ha)
Total area designated for conservation management (land dedicated to conservation or environmental protection on a long-term basis, including conservation set-asides and environmentally sensitive areas that have been kept out of production such as steep slopes and riparian buffers) / Area (ha)
How many hectares designated for conservation management are under strict preservation (i.e., no harvesting or other activities)? / Area (ha)
How many hectares designated for conservation management are being managed for restoration? / Area (ha)
Area covered by infrastructure such as administration offices, housing, factories, etc. / Area (ha)
Other areas: / Area (ha)
Do you have records of farm land use or changes to farm land use from 1999 to the present time? / Yes / No
Have any natural ecosystems been altered or cleared on the farm after November 1999? / Yes / No / Unknown
Specify the types of infrastructure on farm and fill in the quantity in each case:
Facility / Quantity / Facility / Quantity / Facility / Quantity
Offices / Laboratory / Employee dining area
Processing areas / Health centre / Housing divisions
Workshops / Plant nursery / Waste treatment
Agrochemical store / Boilers / Fertilizer airstrip
Diesel/gasoline store / Warehouses / Irrigation system
Fertilizer store
Dry mill(s) / Schools / Pumping station/ hydro-electric
Water resources on farm: / Rivers (Specify number):
Dams (Specify number):
  1. FARM CROPS AND PRODUCTION LEVELS

Please indicate recent and anticipated production levels by completing a separate tablebelow for every crop that is intended to be commercialized as Rainforest Alliance CertifiedTM. For “total quantity harvested or anticipated,” please enter actual quantities for prior time periods and estimated quantities for future time periods, for each year within the three-year duration of the certificate with corresponding total crop area for the particular year. For instance, when applying for a new certificate, please provide estimated quantities for all three years. When applying for an annual audit in the second year of the certification cycle, please provide actual quantities harvested in the first year of the certification cycle and estimated quantities for the second and third years.

Refer to the SAN List of Authorized Crops for certification.

Crop 1 – crop name / Variety or varieties / Period / Total area planted of this crop (hectares) / Total quantity harvested or anticipated in each 12-month period / Units (kg or other unit for quantity harvested) / Product type (see instructions)
Year 1
Year 2
Year 3
Crop 2 – crop name / Variety or varieties / Period / Total area planted of this crop (hectares) / Total quantity harvested or anticipated in each 12-month period / Units (kg or other unit for quantity harvested) / Product type (see instructions)
Year 1
Year 2
Year 3
  1. PRODUCT HANDLING, SALES, PROCESSING, AND LABELING

Product handling and processing
Does the farm receive certified and non-certified products in the same facilities? / Yes / No
If YES, please describe:
Does farm mix, split, or repackage Rainforest Alliance CertifiedTM products with non-certified products, or does the farm intend to do so? / Yes / No
If YES, please describe:
Does the farm receive products at more than one site (e.g., more than one mill, factory, or processing facility)? / Yes / No
If YES, please describe:
Types of sales: How does the farm sell its products? Please check all that apply:
The farm sells raw materials (un-processed agricultural products) / Yes / No
The farm sells processed or dried raw materials (e.g., fermented cocoa or roasted coffee beans) / Yes / No
The farm processes raw materials into value-added products / Yes / No
If YES, what finished products does the operation produce?
The farm retails finished products / Yes / No
Name of first buyer of your crop / Location (City/Country) / Contact details (Name and e-mail) / Annual quantities (tons, kg)
  1. LABOR

Please answer the following questions for all of the organization’s employment (including planting, tending, and harvesting crops; crop processing; and farm administration and management) over the past 12 months. Include all workers that were employed at any time during the past 12 months, including seasonal workers.

Summary of LOCALfull-time, year-round workers: / Number of full-time year-round female workers: / Number of full-time year-round male workers:
Summary of LOCALpart-time, year-round workers: / Number of part-time year-round female workers: / Number of part-time year-round male workers:
Summary of LOCALseasonal or temporary workers (includes both full-time and part-time): / Number of temporary and seasonal female workers: / Number of temporary and seasonal male workers:
Summary of NON-LOCALfull-time, year-round workers: / Number of full-time year-round female workers: / Number of full-time year-round male workers:
Summary of NON-LOCAL part-time, year-round workers: / Number of part-time year-round female workers: / Number of part-time year-round male workers:
Total number of workers employed by the organization (should equal the sum of the ten numbers above): / Total number of workers:
Are there labor organizations or workers’ union active on farm? / Yes / No
If YES, please describe:
If there is a labor union active on farm, please provide contact details here:
How many members does the union have?
  1. TRAINING

Did farm workers receive training or support during the past year? / Yes / No

If YES, please complete the following table to summarize training or support provided to farm workers over the past 12 months. Do not include training provided to workers in processing operations. Training or support includes classroom training, field demonstrations, and other forms of hands-on learning and support. Please complete one row for each topic on which training or support was provided. To fill in the first three columns, please use the categories listed below.

Training topic (see categories below) / Who provided the training? (see categories below) / Who received the training? (see categories below) / What crop was the primary focus of the training? / How many people were trained?
females / males
Categories for the “training topic” column (please use the corresponding number in the table above) / Categories for the “who provided training” column (please use the corresponding number in the table above) / Categories for the “who received training” column
Environmental /
  1. Ecosystem conservation or wildlife protection
  2. Water quality protection (including water treatment)
  3. Integrated waste management
  4. Climate change adaptation or mitigation
/ Organization staff or representative /
  1. Plantation technical staff (e.g., staff agronomists or foremen)
/
  1. Hired workers
  2. Individual farmers (typically group members within group certificates)

Social /
  1. Fair treatment of workers (e.g., hiring practices, labor practices, discrimination)
  2. Occupational health and safety
  3. Community relations
/ SAN member /
  1. CEFCA (Côte d’Ivoire)
  2. FIIT (Guatemala)
  3. Fundación Natura (Colombia)
  4. ICADE (Honduras)
  5. Imaflora (Brazil)
  6. ProNatura Sur (Mexico)
  7. Rainforest Alliance
  8. RSPB
  9. SalvaNatura (El Salvador)
  10. Other SAN member

Agronomic /
  1. Crop selection, rehabilitation or replanting
  2. Integrated pest management
  3. Pesticide selection, storage, safety, or record-keeping
  4. Water management (including irrigation)
  5. Nutrient management or soil fertility management
  6. Soil conservation (e.g., erosion control)
  7. Product quality, hygiene, or food safety
  8. Livestock management

Other organization /
  1. Other non-governmental organization, research center, or university
  2. National or local government extension service
  3. Representative or technical staff of a trader, buyer, or retailer
  4. Representative or technical staff of a farm input or equipment company (e.g., pesticide company)
  5. Private consultant
  6. Other

Farm systems /
  1. Farm planning, record-keeping, or social/environmental management systems
  2. Farm business management (including financing and financial book-keeping)

  1. SUB-CONTRACTED ACTIVITIES

List all the companies or persons that you have sub-contracted to carry out various activities within the farm e.g. crop protection products application, security, waste management etc.:

Company/Person name / Contact details / Activity
  1. FURTHER INDICATOR INFORMATION

Water consumed (Liters/month)
Waste water treated (Liters/month)
Pesticides usage (indicate quantities used per year) / Class I / Class II / Class III
Others - specify
Species identified on the farm / Flora / Fauna
Stream sides and water bodies (Kilometers)
Minors below 18 years benefited with education
Do workers have access to potable water? / Yes / No
Do full-time workers earn at least $2/day? / Yes / No
Number of serious accidents
Amount of certified product (Kg, L, or units) / Produced / Sold as certified
Markets the certified products are sold to (Percentages) / Domestic / International
%
enter text.% / .%
  1. STATEMENT AND SIGNATURES

  • I attest that the information provided in this application is accurate and complete, to the best of my knowledge.
  • I have read and understood the current versions of the Sustainable Agriculture Network Standard for Sustainable AgricultureSAN 2017 version 1.2
  • I have read and understood and I am committed to comply with the certification requirements.
  • I acknowledge that [Certification Body] may subcontract auditors to carry out the service requested.
  • I will provide all necessary information to auditors in order to evaluate the farm and all facilities and activities within the certificate scope.
  • I will keep a record of all claims presented to my organization in relation to product compliance with the relevant standards and will make these records available to [Certification Body]. I shall take adequate actions in regard to such claims as well as to any deficiency of products or services which may affect compliance with certification requirements. I shall document actions taken.
  • I will make certification claims only in relation to the certification scope.
  • I shall not employ the certified product in a way that [Certification Body] loses prestige and will not include any declaration of certified product which may be considered as erroneous or unauthorized by [Certification Body].
  • Upon suspension or cancellation of certification, I will discontinue use of all public affairs that contain any reference to certification, and return all certification documents that [Certification Body] may request.
  • I will use certification only to indicate that certified products are in conformity with specific standards.
  • I will make an effort to guarantee that neither the certificate nor the report, nor any parts of these, are employed in a misleading manner.
  • I will comply with [Certification Body]’s requirements when mentioning product certification in media such as documents, brochures or publicity.
  • I acknowledge, without limitation, the decision of [Certification Body] regarding processing of this application.

Approved in representation of: / Name of organization seeking certification
Date: / Indicate date
Full name of the client representative authorized to sign this Statement: / Indicate name
Client Representative’s signature and company stamp:

FOR AFRICERT’S USE ONLY:

Application reviewed and approved by: / Name of CB personnel
Date of final review and approval: / Indicate date

1

Form No. / Written by/date / Authorized by/date / Revision date (yymmdd) / Page
AC 01e / CM/ 2018 / JM/ 2018 / 180101 / 1 of 11