APPLICATION FOR FIELD AND STORAGE SITE INSPECTION
NOXIOUS WEED SEED FREE FORAGE & MULCH
APPLICANT
Member No.
GROWER
County
County
Name
Name
Address
Address
City
State
Zip
City
State
Telephone
Telephone
Cell phone
Cell phone
Residence: Township
Sec.No.
Residence: Township
Zip
Sec.No.
INSTRUCTIONS:
1.
2.
3.
4.
5.
6.
7.
Use a separate application blank for each grower.
Apply 4 weeks prior to EACH cutting and for EACH crop to be inspected.
List each field separately.
Sign the application; send original to MCIA and keep a second copy for your records.
Indicate field location, storage site location and field number on page 2 of application or attach maps.
Enclose payment with application.
Contact your Field Supervisor prior to harvest to arrange inspection.
FIELD
NUMBER
CROP
NUMBER
OF
ACRES
APPROX.
HARVEST
DATE
*CORRESPONDING
SEED FIELD NUMBERS
(If applicable)
SERIAL
NUMBER
(office use only)
*If mulch field is also being inspected for seed production, list the corresponding field number from the seed field application.
The undersigned affirms that standards, regulations and procedures published by the Minnesota Crop Improvement Association will be followed
in producing, processing and handling product from the fields included in this application.
Signature of Applicant
App for Field and Storage Site Inspection – Forage & Mulch
Controlled Version – 4/21/15
Date
Forage & Mulch
Page 1 of 3
Print Date: 2/9/2016
© 2015 Minnesota Crop Improvement Association
SKETCH THE FIELDS & STORAGE SITES TO BE INSPECTED
Show landmarks such as tree lines, building and adjacent fields to help inspector locate fields. Each large square represents one section (640
acres). Dotted lines divide section into quarters (160 acres). Show fields to be inspected in the proper quarters of the sections. Give county,
township name and section numbers below diagram. For townships with more than 36 sections, give township and range numbers. Place field
number from other side of application in each field to be inspected.
County
County
Township Name
Section
Township Name
Section
Township No.
Range No.
Township No.
Range No.
NORTH
WEST
EAST
SOUTH
County
County
Township Name
Section
Township Name
Section
Township No.
Range No.
Township No.
Range No.
App for Field and Storage Site Inspection – Forage & Mulch
Controlled Version – 4/21/15
Forage & Mulch
Page 2 of 3
Print Date: 2/9/2016
© 2015 Minnesota Crop Improvement Association
MINNESOTA CROP IMPROVEMENT ASSOCIATION
1900 Hendon Ave.
St. Paul, Minnesota 55108
APPLICANT
Member No.
Name
FOR MCIA OFFICE USE ONLY
Check No.
Amount
Check No.
Amount
If other than Applicant:
Address
Paid by
Member No.
County
FEES (See Fee Schedule)
SEND PAYMENT WITH APPLICATION
Membership ---
Acres
---
Late Fee
Acreage Fee
Late Application Fee
Membership Fee
Payment for Previous Bill
CREDIT APPLIED
$
AMOUNT OWED ON
PREVIOUS BILL
$
PAYING FOR FOLLOWING GROWER(S):
1) MEMBER NO.
TOTAL SUBMITTED TO MCIA
NAME
AMOUNT PAID
FEES
See Fee Schedule for the applicable program.
You may include fees for multiple applications on one form.
Fee schedules available from Minnesota Crop Improvement
Association or www.mncia.org.
$
2) MEMBER NO.
NAME
AMOUNT PAID
AMOUNT APPLIED TO
THIS APPLICATION
$
$
SEND PAYMENT WITH APPLICATION
Make checks payable to
Minnesota Crop Improvement Association
App for Field and Storage Site Inspection – Forage & Mulch
Controlled Version – 4/21/15
Forage & Mulch
Page 3 of 3
Print Date: 2/9/2016
© 2015 Minnesota Crop Improvement Association